Ep 49 Roshcast Emergency Board Review
Welcome back rush. Cast for episode forty nine. I'm not Gupta an mega ball and we're back with more hired. Emergency Medicine Board Review. Let's jump right into some questions. Let's start with little humans and Rashes for the first question. An eleven year old boy developed an itchy painful air rash on his hands forums and face one day after hiking in nearby woods. You're exempt shows linear feminist papiers over his forms and swelling and air theme. Oh around his eyes cheeks and forehead. He suspected Poison Ivy. The patients mom tells you he's had a reaction poison ivy before which of the following is most likely to improve the course of zone us. Is it a oral diphenhydramine? Every six hours be three week. Prednisone taper see topical one percent hydrocortisone three times daily or D. top go columbine lotion twice-daily a lot of these sound like good options. So let's use the process civilization here. The first big thing to pick up on here is that providers from poison ivy is not histamine mediated does not sound answer choice. A oral diphenhydramine choice. E topical one percent hydrocortisone. That's useful for local contact dermatitis. But it's not recommended for long durations on the face since our little guy has poison ivy. That's pretty widespread and waltzes face and eyelids. This treatment is an appropriate choice. Decal my lotion is useful for controlling symptoms but does not change the course of illness. So the answer here is choice. B Three Week prednisone taper. Our patient has allergic contact dermatitis from Poison Ivy. This is a delayed type hypersensitivity reaction and it may not present for seven to ten days. After exposure with repeated exposures reaction can develop within twelve hours though which is what happened here. Mega just to reiterate rash typically present it typically presents with itching and redness followed by poppies vesicles in bullet in a linear arrangement and treatment for poison ivy is generally top. Go High Potency Corticosteroids. But our patient has an extensive reaction that involves the face. You should get a two to three recourse of tapering systemic corticosteroids. I knew that seems like a long course but the rashes fairly likely to rebound with a shorter course. Naci to know at what H. Children Begin to present with allergic contact dermatitis similar to adults. That's usually around three to eight years of age and interestingly it's because prior to this they have an impaired ability to react allergens all right. Now you're for the next one and just like a regular shift. You never know what you're going to get. We're moving from Rascist P. E. Which of the following patients will benefit most from receiving tissue plasminogen activator for acute pulmonary? Embolism detected in the emergency department is a fifty five year old man with heart of one hundred blood pressure of eighty over forty. Restri- read of twenty four and oxygen saturation. Ninety two percent is a B. Fifty five year old man with heart rate of one forty-five pressure of one. Thirty six over eighty six Restri- read of twenty four in oxygen saturation of ninety two percent. See Fifty five year old woman with a history of Lupus with a heart rate of one hundred blood pressure. Went Sixteen over eighty six breast rate of twenty four in action situation. Eighty-five percent or D Fifty. Five year old woman with a heart rate of one. Ten Blood Pressure of one twenty two over eighty respiratory rate of twenty four and oxygen saturation eighty two percent with evidence of right ventricular dysfunction on Echo. Well only one of these patients presenting with humid amick instability. And that's the answer choice. A with the blood pressure of eight over forty aggressive treatments like Ta for a Pe should probably be considered inhuman Unstable patients. I was tempted to answer choice. See too though the woman with lupus. Who isn't holding a great to? Sir WHY BURDENS E. Mail the main teaching point. Here you're going to give to the human dynamic unstable patient. Although the woman with lupus is an holding great. Oh to sad. She's much more stable and other therapies should be tried first and just as a general reminder on GPA TPAO accelerates license of trombone in it's used in many different disease processes like m. i. Stroke and Acute Pe Administration can lead to humid amick improvement in patients with acute p. But it really needs to be weighed against the risk of major bleeding persistent hypertension or shock. Dude acute pulmonary. Embolism is a widely accepted indication for systemic thrombosis. Patient in choice speed has tacky cardio but is otherwise not naming chloe stable in the patient choice. D has evidence of right ventricular dysfunction on Echo but is otherwise also amicably stable. In these scenarios routine thron politic's is not recommended but make sure to assess each independently and decide on the risks and benefits on a case by case basis as we give them this patient. A lifesaving dose of a woman is brought in unresponsive. She and her friend had finished eating sixty minutes earlier when she collapsed suddenly to the floor. While talking a blood gas demonstrate severe metabolic acidosis which of the following foods is the most likely cause. Is it a apricot kernels? Be Fava beans. See peanuts were D- poppy seeds sudden collapse in metabolic acidosis through describing cyanide poisoning from choice a apricot kernels. Good pickup. And we don't see these often. This is critical. Emergency Medicine to recognize and treat cyanide binds decided chrome oxidise within the Mitochondria. This results in an abrupt cessation of Electron Transport Oxidative phosphorylation not surprisingly. This is what leads to the severe metabolic acidosis. That's a hallmark feature of cyanide poisoning. In addition to acidosis patients can present with severe dyslexia loss of consciousness seizures and cardiac arrhythmias very high levels of cyanide can cause coma cardiovascular collapse and even death and you knew the apricot kernels were a source of cyanide. What are some other sources that we should look out for other sources of cyanide to look out for include cyanide salts smoke inhalation fumigation for insects sodium nitrate oxide pits of Cherries and peaches cigarette? Smoke an acetone. Nitrite and interestingly inhale cyanide is associated with the smell of bitter almonds so look out for that if you have a good sense of smell even though the question didn't ask for let's talk about treatment briefly to first line treatment of cyanide. Toxicity is drowsy. Cabalanasian a drastic a bellman bind cyanide to make Santa Coca Bellman which is nontoxic. If OCCC development isn't available you can also give nitrites aimal nitrate which is inhaled or sodium nitrite which is given intravenously. Both of these induced met Hemoglobin Nimia and met Hemoglobin binds cyanide. More strongly than the ferric ion of site or chrome oxidise effectively creating a cyanide sink. There's also sodium sulfate which through the enzyme Rodney's creates sign. Eight from cyanide is less toxic and excreted by the kidneys but remember that Hydroxy Kabala mean has truly replaced the other treatment options because of its low toxicity and efficacy. Also inducing Matt. Hemoglobin might not be ideal in many Sinai toxicities especially in smoke inhalation and possible common carbon monoxide poisonings. Just who really drive this home? Hydroxy Cabal mean is a pretty safe treatment. Option for cyanide. Toxicity severe uncertain about the diagnosis. Just give the Hydroxy Kabala mean and definitely don't wait for confirmation in severe metabolic acidosis elevated lactate which signed exposure me have been possible. Just give the hydroxyethyl Ballymun. In addition to the Sinai toxicity. Remember to treat other abnormalities as appropriate. This can include treatment with Oxygen Christopher Lloyd Sodium Bicarbonate and visa processes for hypertension as well. Let's quickly review the other answer? Choices patients taking mono meet oxidation. Inhibitors should avoid foods high in tier mean like wine aged cheese answer choice. B Fava beans choice. See Peanuts can cause severe allergic reactions and foreign body aspiration and kids but it is not a source of cyanide. Choice poppy seeds. They contain small amounts of naturally occurring. Opiates Okay it's a busy resuscitation. Bay after tweeting the Sinai toxicity. Your calls over to triage for Lightening Strike Victim. Which of the following is due to the intense thermal radiation seen in lightning strikes. Is it a cataract formation? Be Hypertension Cardia. See midrise or detain panic. Membrane rupture leading strikes caused injuries via both acute thermal radiation and widespread electrical damage. Anti-choice de Tim Panic. Membrane rupture is due to rapid pressure changes from surrounding thermal radiation. That's right also remember that. Lightning can cause burns that appear benign leaving the external tissue untouched but can destroy the deeper fat and muscle delays in treatment can lead to Rapto multi organ failure and death. In addition to thermal radiation the actual current through the body can lead to cardiac arrhythmias and ocular neuro vascular in cutaneous injuries ocular injuries include bilateral cataract formation retinal detachment and you've Vitus near Vascular. Injuries include transient vasoconstriction in transient permanent autonomic dysfunction causing Madrid Isis and he's a Korea and seizures cutaneous injuries include punk. Date Linear Burns as well as the path of Monica Lichtenberg figures. Let's go for the other answer choices. Choice e bilateral cataract formation. This is the most common ocular damage damage seen post lightening strike. But it's caused by electrical damage not thermal damage as you just said choice. B hypertension tacky cardio. These are caused by sympathetic nervous system. Activation in choice see. Madrid is is due to autonomic dysfunction. Only Tim Panic Membrane rupture on that list to sue to thermal radiation. And how long should you monitor a pregnant patient? Who STABLE AND ASYMMETRIC? After lightning strike pregnant? Women should be monitored for at least four hours post lightening strike for continuous fetal monitoring. Hope none of our listeners. Eating Fried Chicken right now if so you might want to stop this next one. At thirty year old woman presents to the with the four day history of bloody diarrhea and abdominal cramping that started two after eating at her favourite Fried Chicken restaurant boyfriend at the same food and has similar symptoms. The patient's vital signs are within normal limits. Physical exam is significant for moist. Mucous membranes. Brisk capillary refill and mild diffuse tenderness to palpitation of the optimum which of the following is the most appropriate management of this patient's illness is it a admit for Ivy's at the reminding rehydration be admit for IV rehydration and observation resolution of Diarrhea C. Discharge home what ciprofloxacin or D. discharge with Metronidazole are patient and her boyfriend. Likely had some undercooked poultry in are infected with campylobacter. June I- treatment is with answer choice. Z. Discharge home would ciprofloxacin right and this person with Moist Mucous. Membranes Brisk capillary. Refill certainly won't require admission and Ivy. Rehydration thank you. Beijing period for campylobacter detainees to six days patients typically present with bloody diarrhea nausea vomiting abdominal cramping and fever and the illness usually lasts for two to ten days treat. Severe disease is with Ciprofloxacin Leva flocks or is it through my son. Remember that lead complications of capable backtra include reactive arthritis and John Burris Syndrome and as for answer choice de Metronidazole? That's the treatment of choice or antibody. It does not cover campylobacter and would not be appropriate here all right now g. for the last question of this episode a fifty four year old man with a history of HIV. Recent CD. Four count of eighty-five presents with a headache and confusion for three days while the he has a seizure which resolves spontaneously electrolytes are all within normal limits. Cat Scan demonstrates multiple subcortical ring enhancing lesions which of the following medication. Regimens should be given. Is it a amphotericin? B B Gyn Cycle. I Garnet See pyramid thiamine sulfur Lou Bourne or D. trimethyl Prim Sulfur mkhsel. Our patient has a CD. Four count less than one hundred. A headache confusion seizures and subcortical ring enhancing lesions on C. T. They're definitely describing toxic plasmas here which is treated with the answer. Choice see pure methane selfish and look of. Oran. Don't confuse talk so would. Cns Lymphoma Sina. Some fomer also causes ring. Enhancing lesions in patients with AIDS lesions in this case are usually solitary in located in the Peri ventricular white matter in addition symptoms and these patients are usually gradually progressive over months rather than days as in our patient. Do you remember why we give Liqun Lavar in or full Inuk? Acid is given as an adjunct to pyramid demean to limit toxic effects. So that's great for first line but what are the second line treatment options first. Second Line think of Clinton Mice in Plus Pyramid Demeaning Lugovoi Warren or Tova Cohen Plus Pyramid demeaning. Luca Voeren. Okay let's go the other answer choices too choice a amphotericin b. that's the treatment for cryptococcal meningitis. And this condition that tees usually normal and then oh p would demonstrate leukocyte hostess and a positive cryptococcal Antigen answer choice B Ganciclovir Foscarnet. That's the treatment for C. V. Retinitis or encephalitis Siemian sufferers usually causes multi focal micro. Joel's and ventricular encephalitis on emory and choice de trimethyl himself. A macos all that's actually used for chronic suppression of supplies Moses to prevent relapse after initial treatment. Final question on this topic before the rapid review to know what infection aside from HIV is associated with primary CNS lymphoma primary CNS lymphoma that's also associated with Epstein Barr virus all right. Let's close out this episode with a rapid review. Localized reaction from Poison Ivy can be treated with topical high potency. Corticosteroids extensive reactions are reactions involving the face or genitalia needed two to three week. Course of tapering. Systemic steroids persistent hypertension or shock due to acute pulmonary. Embolism is the only widely accepted indication for systemic Lices severe metabolic acidosis as a homework creature cyanide poisoning treatment is with hydroxy Cabalanasian. Lightning strikes caused injuries via both thermal mediation. In widespread electrical damage undercooked poultry is associated with infection from campylobacter ginny. This can present with bloody diarrhea. Abdominal cramping and vomiting treatment is with fluoroquinolone or. Is there my son? Admission is rarely required. Subcortical ring enhancing lesions on ct in an HIV patient. See for less than one hundred is indicative of toxic. Pause Moses and treatment is with pyramid selfish and Luca Voeren. Cns Lymphoma also causes ring. Enhancing lesions in patients with AIDS believes in this case are usually solitary and located in the Peri ventricular white powder symptoms are also gradually progressive over months rather than days. That wraps up rush has episode. Forty nine be sure to also check out the blog for questions from this episode Empire Votes Related Images tables as well as bonus teaching points. Don't forget to follow us on twitter at RUSH CAST. And you can always email us at rush. 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