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TEST FOR CHEST PAIN, HEADACHE AND NEUROLOGIC,
SAEM PEDS, SAEM - PROCEDURES, PSYCH EMERGENCIES,
DERM, SAEM TOX, INFXN, OPTHO, FOREIGN BODIES,
SAEM AMS, 2017 CV, 2017 TRAUMA, SAEM MISC, SAEM -
SHOCK AND SEPSIS, ENVIRONMENT AND ENDOCRINE,
PULM EMERGENCIES
A 70 year old woman presents with chest pain that began 2 hours ago. She describes it as substernal radiating to her jaw and left shoulder; there is no other area of pain or radiation. She took an aspirin at home but the pain is not better. She also took 3 sublingual nitroglycerin tablets en route to the hospital. Her initial EKG shows ST elevation in the anterior leads >2mm and ST depression in the inferior leads. The nurse has already administered oxygen, placed her on an EKG monitor, and attained IV access. You order beta-blockade and nitroglycerin for pain relief, and the supervising resident asks you which of the following should be done next: A. Call her primary care physician. B. Send her to radiology for a good-quality chest X-ray. C. Give her a GI cocktail to check for pain relief from this.
D. Call cardiology for a decision between thrombolytic and percutaneous coronary intervention. E. Call cardiology The answer is D. This patient is having an acute myocardial infarction. AMI is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered - selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection. A 72-year-old male presents with five hours of substernal chest pain and pressure despite taking three sublingual nitroglycerin. You order an EKG. What findings on the EKG would indicate that this patient is potentially a candidate for thrombolytic therapy? A. Ventricular tachycardia B. ST-segment elevation of at least 1 mm in two or more contiguous leads C. ST-segment depression of at least 2mm in any precordial lead D. Atrial fibrillation with a rapid ventricular response The answer is B. "Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option)
B. anteroseptal MI C. right-ventricular MI D. pericarditis E. pulmonary embolism The answer is C. The ST-segment elevation in the right- sided lead V4R is strongly suggestive of right-ventricular MI. A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent substernal chest pressure. A report from the patient's primary care physician's office states that an EKG performed four days ago was completely normal. Repeat EKG in the ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What intervention would be indicated to provide definitive management for the findings seen on EKG in this patient? A. Urgent placement of a cardiac pacemaker B. Radiofrequency ablation C. Emergent revascularization with thrombolytics or percutaneous coronary intervention (PCI) D. Continuous cardiac monitoring for 24-48 hours The answer is A. "In the face of an AMI, the risks of complete heart block are much greater when new or preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic placement of a ventricular demand pacemaker is indicated." Which coronary vessel is usually the cause of the myocardial infarction in a patient with ST elevation in V1, V2, and V3? A. right coronary artery (RCA) B. left anterior descending (LAD) C. right ventricular branch of the right coronary artery D. left circumflex artery
E. posterior descending branch of the right coronary artery The answer is B. This EKG pattern is consistent with that of anterior wall myocardial infarction (MI). The LAD supplies the anterior wall of the myocardium. The left circumflex artery, the LAD, or a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion of a branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF and I, aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in leads II, III and aVF causes an inferior MI. The right ventricle is usually supplied by the RCA or, less commonly, a dominant left circumflex. ST elevation in leads V4 and V5 of a right-side leads EKG suggests infarction of the right ventricle. A posterior MI (ST depression in V1-V3) results from occlusion of the RCA, its posterior descending branch, or a dominant left circumflex. A 51-year-old male with long-standing hypertension presents with abrupt onset of severe chest pain radiating to the back. He describes a tearing sensation. Vital signs are HR 110, BP 175/105, RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are all normal. CXR is as shown below. What diagnostic test would be most appropriate for making a definitive diagnosis at this time? [image] A. MRI of the thoracic spine B. Esophagram using Gastrograffin C. CT of the chest with IV contrast D. Aortogram The answer is C. CXR source: http://cdemcurriculum.org/ssm/cardiovascular/images/cxr_with_widened_media stinum.jpg http://cdemcurriculum.org "CT of the chest is the test most often used to confirm the diagnosis of aortic dissection. CT is readily available in most Emergency Departments, and has a sensitivity of 83-98% and specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits associated with the use of CT include
A 60 year old male with known coronary artery disease presents complaining of recent chest pain. The chest pain typically occurs after exertion and lasts about 15 minutes. He takes a sublingual nitroglycerin or rests and the pain subsides. He is currently pain free. He has had similar episodes for the last 6 months with no change in frequency or intensity of the chest pain. He most likely has: A. acute myocardial infarction B. stable angina C. unstable angina D. acute coronary syndrome E. variant (Prinzmetal's) angina The answer is B. Acute coronary syndrome is a spectrum of myocardial ischemia through myocardial necrosis. The spectrum includes unstable angina, stable angina and acute myocardial infarction. Unstable angina is of new or recent onset, of changing character, or angina at rest. Stable angina or angina pectoris is chronic and episodic, usually lasting 5 to 15 minutes and relieved by rest or nitroglycerin. Variant angina usually occurs at rest, often precipitated by tobacco or cocaine use. It is defined as ST elevation that resolves as pain goes away. It is thought to be due to artery spasm. A 65-year-old female presents 2 weeks after an MI complaining of chest pain, fever, and shortness of breath. She has a new friction rub on exam and a leukocytosis. She most likely has: A. pneumonia B. Dressler's syndrome C. congestive heart failure D. pulmonary embolism E. new myocardial infarction The answer is B. Dressler's syndrome is fever, pleuritis, leukocytosis, pericardial friction rub, and evidence of pericarditis or
pleural effusion occurring several weeks after MI. It is thought to be autoimmune in nature and is treated with NSAIDs. A 60 year old male presented to the emergency department with chest pain. He subsequently became unresponsive. The monitor shows the rhythm below. The rhythm is: [image] A. ventricular tachycardia B. atrial flutter C. atrial fibrillation with rapid ventricular response D. sinus tachycardia The answer is A. Ventricular tachycardia is wide and complex. It is distinguished from supraventricular tachycardia by width and morphology of the QRS complexes. (Though there are numerous exceptions, supraventricular tachycardias usually exhibit narrow QRS complexes with morphology similar to that when the patient is in sinus rhythm.) 60 year old male presents to the emergency department with chest pain. His monitor strip, shown below, reveals: [image] A. second degree AV block Mobitz Type 2 B. second degree AV block Mobitz Type 1 C. complete heart block D. first degree AV block The answer is A. Mobitz type 2 is characterized by an unexpected, non-conducted atrial impulses. The R-R interval and P-R intervals are constant. Of the following choices, which diagnosis is most likely in a 50-year old male with substernal chest pain and the EKG shown in the Figure? [image]
B. hypertensive crisis C. white-coat hypertension D. acute hypertensive (non-emergency/non-urgency) episode E. moderate hypertension The answer is B. Elevated blood pressure in the setting of optic disk edema is a hallmark of malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While hypertensive urgency is not consistently defined in the medical literature, this patient's presentation indicates that there is some end-organ damage and thus the diagnosis is malignant hypertension. The "white-coat" syndrome, in which patients' blood pressures are elevated only in the clinical setting and not at home, has been shown to account for as many as a fifth of all cases of newly diagnosed "hypertension." Understanding of this phenomenom is important for emergency physicians, since its frequency explains why patients should not be given a diagnosis of new-onset hypertension based on E.D. measurements. A 29-year-old male presents to the emergency department complaining of substernal chest pressure. The patient used cocaine and alcohol 3 hours prior to admission. On exam, the patient has a blood pressure of 160/100 mm Hg and heart rate of 150 beats per minute with ST-segment changes in the inferior leads on EKG. Which of the following is the best medication to treat the patient's cardiovascular status? A. Lidocaine B. Lorazepam C. Metoprolol D. Phenoxybenzamine The answer is B. In a patient with suspected myocardial ischemia secondary to cocaine abuse, beta blockade is probably contraindicated as it may lead to uncontrolled alpha-agonism and could cause worsening hypertension (this notion continues to be debated). Lidocaine is contraindicated and the use of nitroglycerin is controversial.
A 14 year old presents just after smoking crack cocaine and complains of chest pain. He describes it as sharp and stabbing in the middle of his chest. His EKG is normal. The intern reads the CXR as "negative" but your supervising resident asks you to have another look (see Figure), after which you make the diagnosis of: [image] photo courtesy of eMedicine.com A. Pneumomediastinum B. Pneumonia C. Congestive heart failure D. Aortic dissection The answer is A. Look closely along the left heart border and mediastinum. There is a thin strip of air. Pneumomediastinum and pneumopericardium result from Valsalva maneuvers, barotrauma, asthma, and cocaine inhalation from positive pressure devices. On physical exam there may be a Hamman's sign or mediastinal crunch heard over the precordium. Westermark's sign is dilation of pulmonary vessels proximal to a pulmonary embolism resulting in a cut-off appearance of the vessel on CXR. A 22 year old presents with chest pain and the following EKG: [image] He reports no past medical history and no family history of medical problems. Which substance should you specifically question him about using? A. Methamphetamine B. Heroin C. Ecstasy D. Cocaine The answer is D. Cocaine toxicity can cause a variety of cardiovascular sequelae including: cardiac dysrhythmias, coronary artery vasospasm, myocardial ischemia/infarction, and aortic dissection. The central nervous system is also commonly involved with seizures, intracranial hemorrhages/infarctions and
D. hypoperfusion E. embolic The answer is A. TIAs are associated with increased risk for thrombotic strokes, the result of ulceration of cerebral artery plaque. Patients with TIA have a 5 to 6% percent chance per year of having a stroke. Antiplatelet therapy reduces risk of stroke in these patients. Which of the following is not a known complication of subarachnoid hemorrhage in the immediate several weeks following the initial bleed? A. rebleeding B. hydrocephalus C. hypernatremia D. seizure E. cerebral artery vasospasm C A 36 year old woman presents to the emergency department two hours after the sudden onset of a severe occipital headache and nausea. She has a history of migraine headaches that typically occur in the right frontal area and are associated with an aura. Her temperature is 98.8 degrees Fahrenheit, her neck is supple, and her neurological exam is normal. A non-contrast CT scan of her head is normal. Of the options below, what is the next step in her management? A. Consult a neurologist for evaluation of atypical migraines. B. Perform a lumbar puncture to rule out the possibility of subarachnoid hemorrhage. C. Discharge her home with prochlorperazine and close instructions to return if her symptoms worsen. D. Observe for 6 hours, administer acetaminophen and normal saline, and discharge home if she feels better.
E. Observe for 6 hours and then obtain a repeat CT scan; if normal, discharge home. The answer is B. Sudden onset headache with nausea, vomiting, photophobia, or neck stiffness should raise the concern for spontaneous subarachnoid hemorrhage. Sensitivity of a non-contrast CT scan varies with respect to many factors (e.g. time since bleed) but is generally in the range of 90%; therefore, if the clinical suspicion is high, a lumbar puncture should be performed and a cell count for red blood cells done. Which of the following descriptors of epidural hematoma is FALSE? A. Present in only about 1% of severe head injury patients B. Most often a result of a skull fracture that traverses a venous sinus C. Biconcave blood collection between the skull and dura D. Immediate surgical evacuation is indicated E. Classically associated with a "lucid" interval prior to coma The answer is B. Epidural hemorrhage is most often associated with skull fracture across the course of the middle meningeal artery. Epidural hematomas are least likely in which age group? A. Children less than 2 years B. Prevalence is the same throughout age groups C. Adults excluding elderly D. Children between 8 and 14 E. Elderly The answer is A. Epidural hematoma (EDH) is less likely in children and elderly because of the close attachment of the dura to the periostium of the skull. This is especially true of children less than 2 years because of the added elasticity of the skull. Which of the following symptoms is not associated with epidural hematomas? A. Severe headache
A. In the adult and older pediatric population, lumbar punctures may be performed as high as the L2/L3 interspace and as low as the L5/S1 interspace. B. Patients should be told to keep their neck in maximal flexion throughout the procedure. C. The subarachnoid space extends to the S2 vertebral level. D. Patients are positioned in lateral recumbent position with their lower back arched toward the physician. E. In locating the puncture site, a line connecting the posterior superior iliac crests will intersect the midline at approximately L4. The answer is B. Flexion of the neck does not facilitate the LP to any great extent and may add to a patient's discomfort as well as compromise the unconscious patient's airway. Typically, patients are positioned in the lateral recumbent position but an LP may be performed in the upright seated position. This position may be desirable in the pediatric population where the midline may be more difficult to identify (answer A). Answers B, C, and E are all true statements regarding the anatomy relevant to performing a lumbar puncture. A 65 year old male with a past medical history of poorly controlled hypertension presents with new onset unilateral arm and leg weakness. There is no disturbance of consciousness and there is no evidence of cortical findings (such as aphasia, agnosia, or hemianopsia). What is the most likely location of the vascular obstruction? A. posterior cerebral artery B. middle cerebral artery C. basilar artery D. anterior cerebral artery E. lacunar The answer is E. Lacunar infarcts occur at the small, terminal branches of the vasculature and more commonly occur in African-Americans and patients with diabetes and hypertension. This patient's presentation, evidenced by pure loss of motor function without disturbances in other neurological
modalities, is consistent with an infarct in the internal capsule. Because terminal branches of the vasculature supply the internal capsule, it is frequently affected in patients with diabetes and hypertension. A vascular obstruction in the MCA would affect not only motor functions, but also produce cortical findings such as aphasia or agnosia. A 19 year old female college student presents to the emergency department with fever, headache, and confusion. Physical exam reveals T103. She is lethargic. The HEENT exam is normal, she has nuchal rigidity, and her lungs are clear. Of the following choices, the next step in her treatment should be: A. azithromycin IV B. ceftriaxone IV C. levofloxacin PO or IV D. head CT E. head CT, followed by lumbar puncture The answer is B. In patients with meningitis, early antibiotics administration is of the utmost importance. Antibiotic administration should not be delayed to await diagnostic work up. Ceftriaxone, administered in some regions with vancomycin depending on the resistance profile of likely etiologic agents, is generally considered an antibiotic of choice in meningitis. Azithromycin and levofloxacin do not have good CNS penetration and therefore are not indicated for meningitis. A 24 year old female without prior medical history presents with a one day history of left sided facial weakness. It was preceded by a headache behind her left ear. On exam she is unable to wrinkle her left forehead or close her left eye. The corner of her mouth droops on the left. The rest of the exam is normal. Which of the following would be inappropriate in the care of this patient? A. CT of the brain with and without intravenous contrast. B. Acyclovir. C. Evaluation of Lyme disease if the patient lives in or has visited a Lyme endemic area. D. A short course of prednisone.
can cause hearing loss because of direct compression of the CN VIII. Even though vestibular neuronitis involves inflammation of CN VIII, it is not associated with hearing loss. Benign positional vertigo is caused by loose particles in the semicircular canals that induce a false sense of motion; however, auditory hearing is unaffected. Labyrinthitis, or inflammation of inner ear structures including semicircular canals and cochlea, can result in sensorineural hearing loss. Which of the following might suggest central rather than peripheral vertigo? A. Transient and episodically related to head movement B. Prominent vomiting and diaphoresis C. Sudden onset D. Horizontal nystagmus on extreme lateral gaze E. Diplopia The answer is E. Any cranial nerve deficit should raise the suspicion for a central process as an etiology for vertigo. Some horizontal nystagmus (on extreme lateral gaze) can be a normal finding. A 26 year old woman presents to the emergency department with episodes of spinning associated with nausea, vomiting, and unsteady gait. These occurred three times in the past 12 hours and come on suddenly when she is lying down and turns onto her right side. The spinning is violent and she has vomited several times. Her symptoms resolve spontaneously in 5 to 10 minutes and she feels fine in the interim. She has recently had an upper respiratory infection and has started no new medications. Her neurologic exam is normal. Laying her down quickly over the side of the bed with her head turned to the left reproduces symptoms. Which of the following medications may be effective in preventing further episodes of vertigo? A. Promethazine B. Diphenhydramine C. Meclizine D. Any of the above E. Diazepam The answer is D. This patient has symptoms consistent with benign positional vertigo. It is caused by vestibular stimulation, usually from loose
debris in the semicircular canals. Benzodiazipines are useful because of their sedative effect on the limbic system, thalamus, and hypothalamus. Vestibular neurons are mediated by acetylcholine; therefore, anticholinergic agents (e.g., meclizine, diphenhydramine, promethazine) are effective to minimize vertigo. The arterial distribution in the Figure which is indicated by the letter "A", and shaded black, is the: [image] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. internal carotid artery B. posterior cerebellar artery C. basilar artery D. anterior cerebral artery E. middle cerebral artery The answer is E. The shaded area is the MCA. For further reading, see Hamilton et al, Emergency Medicine: An approach to clinical problem-solving (Chapter 34: Stroke). A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain, progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F). On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is not an acceptable next step? A. Analgesia B. Foley catheter to drain the bladder C. Antibiotics to cover a broad spectrum of organism D. MRI of the spine
