The Challenge Wednesday, November 16th

A 57-year-old woman presents to the emergency department with complaints of severe headache, vomiting, neck stiffness, and chest pain that have occurred over the past several hours. Her medical history is notable for diabetes, hypertension, and dyslipidemia. Her temperature is 99.0°F (37.2°C), blood pressure is 197/124 mm Hg, pulse is 120/min, respirations are 19/min, and oxygen saturation is 98% of room air. Physical examination is significant for papilledema. Urinalysis reveals gross hematuria and proteinuria. The team is concerned for ascending aortic aneurysm dissection. Which of the following is the next best step in the management of this patient?

TW is a 72 yo male (82kg) who presents to the ED complaining of heart palpitations for approximately 2 hours. He said this has happened once before about a year ago, but he didn’t seek care at that time. He as a history of hypertension and hyperlipidemia for which he takes losartan and simvastatin. Upon initial exam his heart rate is 153, BP 141/76, and O₂ saturation 98%. His EKG shows atrial fibrillation with rapid ventricular response (RVR).

Since there is a medical student rotating in your ED today, you ask them what they recommend to control TW’s heart rate. They explain that either agent can be used for chronic maintenance but aren’t sure if that holds true when the patient has RVR. Which of the following is the best teaching point regarding metoprolol and diltiazem for AFib with RVR?

55-year-old female presenting to the emergency department (ED) via emergency medical services (EMS) transport from home for shortness of breath, altered mental status, and new onset palpitations. The patient has a past medical history of hypertension taking amlodipine. Her presenting vital signs include BP 110/62 mm Hg, HR 165 beats/min, RR 26 breaths/min, and temperature 38.9oC.  A 12-lead ECG reveals a wide complex tachycardia with a regular rhythm without prolonged QT internal that is identified as monomorphic ventricular tachycardia. Which of the following interventions would be the best initial option for acute management in this patient?

A forty-two-year-old man is brought to the EMS department from the scene of a traffic accident, where he appeared to be an unrestrained passenger. The patient is confused and unable to answer questions. His temperature is 98.6°F (37°C), pulse 120/min, blood pressure 75/44 mmHg, and respiratory rate 22/min. On physical examination, he has bruising on the sternum and left chest with tenderness to palpation. Cardiac auscultation reveals normal heart sounds without murmurs, rubs, or gallops. He has marked distension of the jugular veins and bibasilar crackles on auscultation of the lungs with equal air entry bilaterally. Examination of the abdominal and cranial nerves is within normal limits. His extremities are cool with prolonged capillary refill and he is diaphoretic. The patient is admitted to the intensive care unit and hemodynamic monitoring is instituted, revealing a pulmonary capillary wedge pressure (PCWP) of 22 mmHg (normal range 8-12 mmHg), a central venous pressure (CVP) of 12 cmH2O (normal range 4). -12 cmH2O), cardiac output (CO) 2.2 L/min (normal range 4-8 L/min) and systemic vascular resistance (SVR) 1800 dynes/s/cm^-5 (normal range 700-1600 dynes / seconds/cm^-5). Which of the following types of shock best describes this patient’s condition?

A 75-year-old man arrives by ambulance to the emergency department very confused. His vital signs are T 40 C, pulse 120 beats/min, BP 80/55 mmHg, RR 25. His wife explains that he injured himself while cooking about a week ago and a few days later his finger became infected and oozing pus. He ignored warnings to see a doctor and even refused after developing fever, chills and severe fatigue yesterday. After an examination by the EMS doctor, he was given antibiotics and infusions. After initial resuscitation with intravenous fluids, she remains hypotensive. Doctors in the ED insert a central venous catheter and begin an infusion of norepinephrine. Which of the following receptors are activated by norepinephrine?

A 68-year-old woman is brought to the emergency room by ambulance after being found by her daughter. She lives alone in her apartment, so it’s unclear when she started showing symptoms. Her medical history is significant for cardiac arrhythmias, diabetes, pericarditis, and stroke 2 years ago. On presentation, her temperature is 98.1°F (36.7°C), blood pressure 88/51 mmHg, pulse 137/min, and respirations 18/min. On physical examination, her skin is cool and clammy. If special tests were obtained, they would reveal dramatically reduced pulmonary capillary wedge pressure, increased systemic vascular resistance, and slightly reduced cardiac output. Which of the following treatments would most directly target the cause of this patient’s low blood pressure?

A 22 yo M with unknown PMHx is brought to the emergency department sustaining multiple gunshot wounds. Upon arrival in the resuscitation bay, his exam is concerning for hemorrhage shock with altered mental status and BP of 82/48 mmHg. Massive transfusion protocol is activated.  After receiving 4 PRBC’s which would be the most  appropriate intervention at this time?

A 58 yo M without significant PMHx is BIBEMS to the emergency department after suffering a motorcycle collision vs car. Physical exam is notable for a Gustilo Type IIIb open fracture in the left lower extremity. The patient states he has no known drug allergies and weighs 121 kg.  Which is most appropriate antibiotic regimen for infection prophylaxis at this time?

A 19-year-old boy comes to the emergency department following an injury during football practice. He fell and landed on his extended neck. He is not able to move his arms and legs since the injury, and complains of neck pain. Vital Signs are HR: 48 bpm, BP: 70/40 mm Hg, RR: 16/min, Temp: 37°C. He has no past medical history other than attention dificiet disorder for which he takes Vyvanse 80 mg daily. Physical examination shows tenderness to palpation at the cervicle area with other notable injuries on the primary and secondary exam. GCS is 15. Non‐contrast C‐spine CT is significant for fracture of C5 and C6 with retropulsion and neurosurgery was consulted. While waiting for neurosurgeon to arrival the trauma team lead says they want to target the blood pressure goal for spinal cord injury. Which of the following is the most appropriate blood pressure goal in this case, taking into the account the concern about neurogenic shock?

The mother brings the child to the emergency room. Her mother reports that the 7-year-old was playing with their dog, who is up-to-date on his vaccinations. When the dog began to play more aggressively, the child suffered a bite to the hand with two puncture wounds from the dog’s fangs. The child is up-to-date on vaccinations and has no medical history. Her vital signs are within normal limits. If this bite becomes infected, what organism is the most likely cause of the infection?

A 14-year-old boy is brought to the ER by his mother for “irritated eyes.” The mother states that 2 days ago she noticed that the patient kept rubbing his eyes. Yesterday, his eyes appeared slightly red. Then this morning he woke up and couldn’t open his eyes properly. The patient’s temperature is 101.3°F (38.5°C), blood pressure is 102/60 mmHg, and pulse is 110/min. Her mother is concerned about his upcoming exams preparation being disturbed by this. On physical exam, extraocular eye movements are intact and the pupils are equal and reactive to light. Which intervention is the best treatment recommended for this patient?

LR is a 78yo male who presents to the ED with a 5-day history of cough, shortness of breath, and subjective fevers. He has a past medical history significant for hypertension, hyperlipidemia, diabetes, atrial fibrillation, CHF, and CKD, and an admission last month for a UTI where he received ceftriaxone. Allergies include penicillin (rash) and sulfa (hives). Upon presentation his vital signs are as follows: temperature 100.7°F, BP 155/88, HR 82, RR 22, O₂ saturation 96% on RA. His labs are unremarkable except a SCr of 1.4 (appears to be at his baseline) and a WBC of 12.2. Which of the following is the most appropriate empiric antibiotic regimen for LR?

A 23-year-old woman comes to the emergency department with 1 day of severe, worsening abdominal pain. Since waking up this morning, she reports severe right lower quadrant abdominal pain with associated back pain and rectal pain associated with nausea and vomiting. She has never had similar symptoms before and has no significant medical history. He is sexually active with multiple partners and rarely uses condoms. She describes an abnormally smelling vaginal discharge a few weeks ago, which she says she was too busy to see a doctor. On arrival, temperature is 103°F (39.4°C), blood pressure is 90/48 mmHg, pulse is 124/min, and respirations are 18/min. The exam shows a poor looking woman who is in distress but able to answer questions. She has allergies to Cefdinir and tetracycline. Abdominal examination shows severe right lower quadrant pain with a palpable, exquisitely tender right pelvic mass. A urine pregnancy test is negative. What is the appropriate choice of antibiotic for this patient?

A 2-month-old infant is brought to the Emergency Department by his mother with the complaint of irritability, decreased appetite, vomiting, and fever for the past 2 days. On examination, the presence of which of the following findings would indicate a diagnosis of meningitis?

A 35-year-old woman comes to the emergency department after fainting. She was visiting her family when she passed out after arriving at their home. She woke up 1 minute later and was in her baseline mental state. Since then, she has constantly felt helpless and weak since that event. She almost passed out again in the emergency room. The patient has a history of obesity and has recently undergone knee surgery with the knee currently immobilized in a brace. She is currently taking metformin, oral contraceptive pills, and sumatriptan. Her temperature is 99.3°F (37.4°C), blood pressure is 72/48 mmHg, pulse is 177/min, respirations are 29/min, and oxygen saturation is 90% room air. Physical examination is remarkable for an anxious young woman who is unable to walk without feeling dizzy. An ultrasound is performed, which demonstrates a dilated right ventricle with septal bulging and a hyperdynamic left ventricle. Which of the following is the most appropriate next step in management?