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/ 389 Qs with Ans &
Definitions.
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?
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,A. Analgesia
B. Foley catheter to drain the bladder
C. Antibiotics to cover a broad spectrum of organism
D. MRI of the spine
E. Hospital admission for neurosurgical consultation in the morning - Answer: The
answer is E. A spinal epidural abscess is a neurosurgical emergency, with the
outcome being dependent on the speed of diagnosis and surgical decompression.
Consequently, urgent neurosurgical evaluation is required. Although an
uncommon disease, intravenous drug abuse, diabetes mellitus, chronic renal
failure, and immunosuppression are risk factors for its development. Antibiotics to
cover Staph. aureus, the most common cause, gram negative bacteria, and
anaerobes are needed. Bladder decompression for symptomatic relief is
important, as is analgesia. For further reading, please see Marx JA. Rosen's
Emergency Medicine. 6th ed. 2006, page 1684.
Which of the following is true about myasthenia gravis?
A. The "atropine test" is diagnostic when 0.5 mg of atropine is given intravenously
and the patient's symptoms improve within two minutes.
B. A myasthenic crisis involves an exacerbation of weakness, especially of
respiratory muscles, often necessitating intubation.
C. Cooling exacerbates the symptoms, and heat alleviates them.
D. It typically presents as an ascending weakness of the peripheral nervous
system.
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,E. Weakness improves as the involved muscles are used repeatedly. - Answer: The
answer is B. Myasthenia gravis is an autoimmune disease that results from
antibodies directed against the acetylcholine receptor (AChR) at the
neuromuscular junction. Destruction of the AchR leads to fewer receptors
available to bind acetylcholine, with a resulting muscle weakness. Ocular
symptoms are usually the first to occur, with diplopia and ptosis being common.
The disease typically worsens as the day progresses because of repeated use of
the muscles involved. Diagnosis is made with the tensilon test, where
edrophonium is given and the patient's symptoms are observed to transiently
improve. The administration of atropine is not a diagnostic test. Cooling helps the
symptoms and heat exacerbates them. A myasthenic crisis is a feared
complication. Patients develop respiratory failure requiring intubation, frequently
for prolonged periods.
A 36 year old woman on chronic cyclosporine treatment for bilateral lung
transplantation visits the emergency department complaining of extreme
headache, nausea and vomiting. Her exam is notable for BP 239/165, normal
cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG
showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely
control her blood pressure, which of the following is TRUE?
A. Nitroprusside would be contraindicated in this patient due to its relatively slow
onset of action
B. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
C. Esmolol works through both alpha-1 and selective beta-2 blockade
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, D. Hydralazine decreases myocardial oxygen demand by decreasing afterload and
would not be useful in this setting
E. Nitroglycerin decreases BP by decreasing venous return and cardiac output -
Answer: The answer is E. Relative to other anti-hypertensive agents, nitroprusside
has an extremely rapid onset of action. Although rare, long-term nitroprusside
treatment may lead to cyanide toxicity in renal failure patients secondary to the
presence of cyanide as an intermediate metabolite. A history of long-term
cyclosporine treatment suggests this patient likely has some degree of renal
insufficiency.
A 14 year-old child presents to the emergency department. His blood pressure is
210/140. He complains of a headache, nausea, and recent blurred vision. Of the
following choices, the best goal for lowering his mean arterial blood pressure is to
have it drop by:
A. 50% in the first hour
B. To normal for his age in the first hour
C. Until symptoms resolve
D. 5% in the first 5-6 hours
E. 25% in the first hour - Answer: The answer is E. A systolic BP of 210 or more, or
a diastolic BP of 140 or greater, defines hypertensive urgency. With end-organs
symptoms, as above, the presumptive diagnosis is hypertensive emergency. In
hypertensive emergencies, the goal is to decrease mean arterial blood pressure by
10-25% within the first hour, thereby alleviating symptoms while not
compromising cerebral perfusion.
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