A 42-year-old woman is brought to the emergency department due to severe headache. Three hours ago, the patient suddenly began experiencing bilateral headache, which rapidly worsened in severity. She also has had neck pain and an episode of vomiting. The patient has had no prior headaches, and medical history is significant for hypertension. Temperature is 38.2 C , blood pressure is 154/92 mm Hg, and pulse is 102/min. Oxygen saturation is 98% on room air. On physical examination, the patient appears in obvious discomfort and keeps her eyes closed. She follows simple instructions, and there is no focal weakness or numbness. Funduscopy shows no papilledema. There is increased resistance to passive neck flexion, and it also elicits pain. Which of the following is the best next step in management of this patient?
A. 100% oxygen inhalation
B. Cervical spine x-ray
C. CT scan of the brain
D. Lumbar puncture
E. Sumatriptan injection
Please open Telegram to view this post
VIEW IN TELEGRAM
❤4👍2
Correct Answer Is C
Subarachnoid hemorrhage (SAH) usually results from rupture of a saccular aneurysm and classically presents with a sudden-onset, severe headache, often called a thunderclap headache. The location of the headache can be highly variable, but it is commonly accompanied by vomiting and photophobia, and some patients may experience a brief loss of consciousness. Neck pain (or stiffness) and low-grade fever are also common due to blood-induced meningeal irritation.
SAH is associated with high morbidity and mortality, and recognition is complicated by a wide range of clinical presentations. Although nearly 20% of patients die before reaching the hospital, approximately 40% present in a normal state of alertness without any neurologic deficit. Noncontrast CT scan of the brain is the initial diagnostic step of choice as it has high sensitivity for detecting blood pooling in the basal cisterns or sulci of the subarachnoid space.
If CT scan is unremarkable and there is still reasonable suspicion for SAH, lumbar puncture is performed to evaluate for red blood cells or xanthochromia. Xanthochromia is a pink or yellow tint of the cerebral spinal fluid (CSF) caused by hemoglobin degradation products (eg, bilirubin) that appear as soon as 2 hours following a subarachnoid bleed and persist in the CSF for weeks.
Administration of 100% oxygen is appropriate therapy for a cluster headache, which presents as a unilateral, severe headache that is usually accompanied by signs of parasympathetic hyperactivity (eg, ptosis, miosis, nasal congestion) on the ipsilateral side.
Cervical spine x-ray is appropriate to evaluate for fracture following cervical spine trauma, but it is not indicated for spontaneous onset of severe headache.
Meningitis can present with fever, neck stiffness, and headache. However, the dramatic onset and rapidly progressive severity of symptoms in this patient should raise strong suspicion for SAH, and given the high mortality associated with unrecognized SAH, a CT scan—which is less invasive and can generally be performed more rapidly than lumbar puncture—is the best next step. If the CT scan is negative, lumbar puncture, which would evaluate for both xanthochromia (from SAH) and signs of meningitis, should be considered. Meningitis patients often have high-grade fever and chills and appear ill.
Sumatriptan can be helpful for migraine headaches. Migraines are often accompanied by nausea and photophobia, but they also typically have a prodrome and are not associated with fever.
Subarachnoid hemorrhage typically presents with a sudden-onset, severe headache that may be accompanied by vomiting, neck stiffness, fever, and loss of consciousness. CT scan of the brain is the best initial diagnostic step.
Please open Telegram to view this post
VIEW IN TELEGRAM
🔥7👍2
A 40-year-old man is brought to the emergency department due to retrosternal and epigastric pain after ingesting an unknown amount of sodium hydroxide–based drain cleaner 45 minutes ago. He has a history of major depressive disorder and a prior suicide attempt. The patient has difficulty swallowing his saliva and is drooling. Temperature is 36.8 C, blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min. Examination shows oropharyngeal erythema and mild edema. The lungs are clear to auscultation. Abdominal examination shows tenderness at the epigastrium without rebound or guarding. Chest x-ray reveals no abnormalities. Intravenous normal saline infusion is initiated. Which of the following is the most appropriate next step in management of this patient?
A. Activated charcoal in water
B. Gastric decontamination with ipecac
C. Intravenous methylprednisolone
D. Neutralization of alkali with dilute acetic acid solution
E. Upper gastrointestinal endoscopy
Please open Telegram to view this post
VIEW IN TELEGRAM
👍2❤1
Correct Answer Is E
Caustic ingestion
Clinical features
Chemical burn or liquefaction necrosis resulting in:
Laryngeal damage: hoarseness, stridor
Esophageal damage: dysphagia, odynophagia
Gastric damage: epigastric pain, bleeding
Management
Secure airway, breathing, circulation
Decontamination: remove contaminated clothing & visible chemicals; irrigate exposed skin
Chest x-ray if respiratory symptoms
Endoscopy within 24 hr
Complications
Upper airway compromise
Perforation
Strictures/stenosis (2-3 weeks)
Ulcers
Cancer
This patient who ingested sodium hydroxide (a strongly caustic alkaline solution) now has pain, dysphagia, and erythema of the oropharynx, which is concerning for caustic esophageal injury. This injury can be caused by ingestion of:
acidic substances, which cause coagulation necrosis (eg, protein denaturation) that results in an eschar, thereby preventing further acid penetration and injury.
alkaline substances (eg, many cleaning supplies), which cause liquefactive necrosis (eg, cell membrane dissolution) that often leads to deeper penetration of tissues and therefore more severe injuries.
Mucosal injury results from contact with the caustic substance (rather than from systemic absorption); therefore, patients often have immediate oropharyngeal, retrosternal, or epigastric pain as well as dysphagia and hypersalivation (eg, drooling). Vomiting and hematemesis may also occur. Patients should initially undergo assessment and stabilization of the airway, breathing, and circulation. Serial chest and abdominal x-rays should be obtained to identify any signs of perforation, such as pneumomediastinum, pleural effusions, or subdiaphragmatic air (none of which are seen in this patient). An upper gastrointestinal x-ray study with water-soluble contrast should be performed in patients with suspected perforation.
The severity of esophageal injury cannot be predicted by either clinical symptoms or the extent of oral injury seen on physical examination. Therefore, in the absence of perforation or severe respiratory distress, endoscopic evaluation within the first 24 hours is recommended to assess the severity of esophageal damage.
Activated charcoal can decrease the systemic absorption of poisons; however, caustic ingestions cause immediate local damage on contact with the esophagus. In addition, charcoal would obstruct the view during endoscopy.
Inducing vomiting with ipecac is not appropriate because it would reexpose the esophagus to the caustic agent and potentially cause further injury.
Corticosteroid therapy has been hypothesized to reduce the risk of late complications (eg, stricture) but has not been shown to be effective. In addition, it may increase the risk of secondary infections.
Because esophageal damage occurs instantaneously, neutralizing agents are not effective. In addition, acid-base reactions are exothermic and could cause further injury.
Caustic alkali ingestion causes immediate esophageal injury with liquefactive necrosis. In stable patients with no evidence of perforation, endoscopy should be performed within the first 24 hours to assess the severity of the injury and guide further management
Please open Telegram to view this post
VIEW IN TELEGRAM
👍5❤1
A 55-year-old woman is brought to the emergency department after being found unconscious in her apartment. En route to the hospital, the patient had a seizure and was urgently intubated for airway protection. Medical history is significant for treatment-resistant major depression, hypertension, and hyperlipidemia. The patient takes imipramine, atorvastatin, and lisinopril. Temperature is 38.2 C, blood pressure is 90/50 mm Hg, pulse is 120/min, and respirations are 14/min. Oxygen saturation is 98% on 40% fraction of inspired oxygen. Examination shows bilateral dilated pupils that are minimally reactive to light. The skin appears flushed. Cardiopulmonary examination reveals clear lungs and normal heart sounds. The abdomen is slightly distended with decreased bowel sounds. Muscle tone and reflexes are normal. Sodium bicarbonate therapy is administered. Sodium bicarbonate is indicated in this patient primarily to treat which of the following?
A. Cardiac toxicity
B. Hyperkalemia
C. Hyperthermia
D. Hyponatremia
E. Respiratory depression
Please open Telegram to view this post
VIEW IN TELEGRAM
👍3
This patient has likely overdosed on imipramine, a tricyclic antidepressant (TCA). Because of the inhibitory effects of TCAs on multiple receptor types, overdose can cause a variety of symptoms, including CNS toxicity (eg, unconsciousness, seizures), anticholinergic toxicity (eg, hyperthermia, dilated pupils, intestinal ileus, flushed skin), hypotension, and cardiac toxicity.
Cardiac toxicity is caused by TCA inhibition of fast sodium channels in the His-Purkinje system and myocardium. This decreases conduction velocity, increases the duration of repolarization, and prolongs absolute refractory periods. QRS prolongation and ventricular arrhythmias (eg, ventricular tachycardia, ventricular fibrillation) may result.
A QRS interval >100 msec or ventricular arrhythmia in the setting of TCA overdose is an indication for sodium bicarbonate therapy. Sodium bicarbonate likely improves cardiac toxicity through the following mechanisms:
Increasing serum pH makes the TCA less pharmacologically active, decreasing its avidity for sodium channels.
Increasing extracellular sodium concentration raises the electrochemical gradient across cardiac cell membranes, decreasing the impact of the TCA-induced sodium channel blockade.
Sodium bicarbonate infusion also improves TCA-induced hypotension, which is caused by alpha-1 adrenergic receptor antagonism in combination with cardiac toxicity, and is the leading cause of mortality in TCA overdose.
Sodium bicarbonate is an adjunctive therapy for treating severe hyperkalemia (or rapidly increasing serum potassium) associated with ECG changes (eg, peaked T waves, short QT interval, increased QRS interval). However, TCA overdose is not associated with severe hyperkalemia.
TCA overdose causes hyperthermia via its anticholinergic effect (ie, muscarinic receptor inhibition) on sweat glands, which decreases sweating and heat dissipation. This anticholinergic effect is typically unaltered by sodium bicarbonate administration.
Sodium bicarbonate administration may increase serum sodium levels; however, this medication is administered to treat cardiac toxicity rather than hyponatremia, which is not typically associated with TCA overdose. In addition, 3% saline, rather than sodium bicarbonate, is the preferred medication for treating severe hyponatremia.
Respiratory depression is not directly caused by TCA overdose but can occur indirectly because of CNS depression (ie, antihistamine effects) or complications of seizure activity. Sodium bicarbonate is unlikely to improve these indirect causes of respiratory depression.
Tricyclic antidepressant (TCA) overdose can cause CNS toxicity, anticholinergic findings, hypotension, and cardiac toxicity. Cardiac toxicity is due to the inhibition of fast sodium channels and may result in QRS prolongation and ventricular arrhythmia. Sodium bicarbonate can improve both cardiac toxicity and TCA-induced hypotension.
Please open Telegram to view this post
VIEW IN TELEGRAM
👍9❤4
Case-based MCQ | #MCQ_78
••••••••••••••••••••••••••••
A 12-hour-old girl in the neonatal intensive care unit has bilious emesis. She was born at 35 weeks gestation by vaginal delivery to a 22-year-old woman who did not receive prenatal care and used cocaine during her pregnancy. The infant has urinated but has not had a bowel movement. She was able to take 2 bottle feeds by mouth but has been vomiting green fluid since the third feed. Birth weight was 2 kg, which is small for gestational age. Temperature is 36.9 C, pulse is 160/min, and respirations are 40/min. The abdomen is distended. The rest of the examination is unremarkable. Abdominal x-ray is shown below. Which of the following is the most likely diagnosis in this patient?
A.Cocaine withdrawal
B.Duodenal atresia
C.Hirschsprung disease
D.Jejunal atresia
E.Necrotizing enterocolitis
••••••••••••••••••••••••••••
A 12-hour-old girl in the neonatal intensive care unit has bilious emesis. She was born at 35 weeks gestation by vaginal delivery to a 22-year-old woman who did not receive prenatal care and used cocaine during her pregnancy. The infant has urinated but has not had a bowel movement. She was able to take 2 bottle feeds by mouth but has been vomiting green fluid since the third feed. Birth weight was 2 kg, which is small for gestational age. Temperature is 36.9 C, pulse is 160/min, and respirations are 40/min. The abdomen is distended. The rest of the examination is unremarkable. Abdominal x-ray is shown below. Which of the following is the most likely diagnosis in this patient?
A.Cocaine withdrawal
B.Duodenal atresia
C.Hirschsprung disease
D.Jejunal atresia
E.Necrotizing enterocolitis
❤8👍2
Case-based MCQ | #MCQ_78
••••••••••••••••••••••••••••••••••••••
Correct Answer Is D
The bilious emesis, abdominal distension, and x-ray findings in this neonate are consistent with jejunal atresia. Intestinal atresia can occur anywhere along the gastrointestinal tract. Atresia of the jejunum or ileum is thought to occur due to a vascular accident in utero that causes necrosis and resorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine. Risk factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications or substances such as cocaine and tobacco. In contrast to duodenal atresia, jejunal and ileal atresia are not associated with chromosomal abnormalities.
A triple bubble sign and gasless colon on abdominal x-ray (above) reflects gas trapping in the stomach, duodenum, and jejunum. Treatment should begin with resuscitation and stabilization of the patient, followed by surgical correction. Prognosis depends on the length of affected bowel as well as the patient’s gestational age and birth weight.
This infant is premature with intrauterine growth restriction (low birth weight) due to prenatal cocaine exposure. After birth, these infants are at risk for withdrawal symptoms, including irritability, tremors, and high-pitched cry. This patient’s bilious emesis and x-ray, however, are highly suggestive of bowel obstruction.
Duodenal atresia is thought to result from failure of the duodenum to recanalize and presents with abdominal distension and bilious emesis. X-ray reveals a double bubble rather than the triple bubble seen in this patient.
Hirschsprung disease can present with abdominal distension and bilious emesis as well as delayed passage of meconium (age >48 hours). This infant is only 12 hours old and is not expected to have passed meconium yet. Because the obstruction is typically at the level of the rectosigmoid junction, dilated loops of bowel would be seen on x-ray, making this diagnosis less likely.
Necrotizing enterocolitis typically presents as abdominal distension, bloody stools, and vital sign instability in premature infants. The hallmark finding on x-ray is pneumatosis intestinalis (extravasation of gas into the damaged bowel wall).
Jejunal atresia presents with bilious vomiting and abdominal distension. Abdominal x-ray reveals a triple bubble sign and gasless colon. Risk factors include prenatal exposure to cocaine and other vasoconstrictive substances.
••••••••••••••••••••••••••••••••••••••
Correct Answer Is D
The bilious emesis, abdominal distension, and x-ray findings in this neonate are consistent with jejunal atresia. Intestinal atresia can occur anywhere along the gastrointestinal tract. Atresia of the jejunum or ileum is thought to occur due to a vascular accident in utero that causes necrosis and resorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine. Risk factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications or substances such as cocaine and tobacco. In contrast to duodenal atresia, jejunal and ileal atresia are not associated with chromosomal abnormalities.
A triple bubble sign and gasless colon on abdominal x-ray (above) reflects gas trapping in the stomach, duodenum, and jejunum. Treatment should begin with resuscitation and stabilization of the patient, followed by surgical correction. Prognosis depends on the length of affected bowel as well as the patient’s gestational age and birth weight.
This infant is premature with intrauterine growth restriction (low birth weight) due to prenatal cocaine exposure. After birth, these infants are at risk for withdrawal symptoms, including irritability, tremors, and high-pitched cry. This patient’s bilious emesis and x-ray, however, are highly suggestive of bowel obstruction.
Duodenal atresia is thought to result from failure of the duodenum to recanalize and presents with abdominal distension and bilious emesis. X-ray reveals a double bubble rather than the triple bubble seen in this patient.
Hirschsprung disease can present with abdominal distension and bilious emesis as well as delayed passage of meconium (age >48 hours). This infant is only 12 hours old and is not expected to have passed meconium yet. Because the obstruction is typically at the level of the rectosigmoid junction, dilated loops of bowel would be seen on x-ray, making this diagnosis less likely.
Necrotizing enterocolitis typically presents as abdominal distension, bloody stools, and vital sign instability in premature infants. The hallmark finding on x-ray is pneumatosis intestinalis (extravasation of gas into the damaged bowel wall).
Jejunal atresia presents with bilious vomiting and abdominal distension. Abdominal x-ray reveals a triple bubble sign and gasless colon. Risk factors include prenatal exposure to cocaine and other vasoconstrictive substances.
👍12❤3🤩1
Case-based MCQ | #MCQ_79
••••••••••••••••••••••••••••••••••••••
A 55-year-old man is brought to the emergency department due to altered mental status. The patient’s wife came home from work and found him confused. He was fine that morning before she left the house. The patient has a medical history of chronic migraines and major depression; he has been out of work for a few months due to the pain. The wife reports her husband has tried “every migraine medication there is” but she does not know which one he is currently taking. Blood pressure is 80/60 mm Hg, and pulse is 125/min. The patient is drowsy and does not answer questions or follow commands. The oral membranes are dry. There is reddening around the face and neck. ECG reveals sinus tachycardia with a QRS duration of 120 msec and frequent premature ventricular beats. Initial laboratory studies are ordered, and intravenous hydration is started. Which of the following is the best next step in management?
A. Amiodarone
B. Atropine
C. Calcium chloride
D. Hemodialysis
E. Sodium bicarbonate
••••••••••••••••••••••••••••••••••••••
A 55-year-old man is brought to the emergency department due to altered mental status. The patient’s wife came home from work and found him confused. He was fine that morning before she left the house. The patient has a medical history of chronic migraines and major depression; he has been out of work for a few months due to the pain. The wife reports her husband has tried “every migraine medication there is” but she does not know which one he is currently taking. Blood pressure is 80/60 mm Hg, and pulse is 125/min. The patient is drowsy and does not answer questions or follow commands. The oral membranes are dry. There is reddening around the face and neck. ECG reveals sinus tachycardia with a QRS duration of 120 msec and frequent premature ventricular beats. Initial laboratory studies are ordered, and intravenous hydration is started. Which of the following is the best next step in management?
A. Amiodarone
B. Atropine
C. Calcium chloride
D. Hemodialysis
E. Sodium bicarbonate
👍2
Case-based MCQ | #MCQ_79
••••••••••••••••••••••••••••••••••••••
This patient with chronic pain has altered mental status, hypotension, signs of anticholinergic toxicity (eg, facial flushing, dry mouth), and a prolonged QRS interval. These clinical features suggest tricyclic antidepressant (TCA) poisoning; TCAs are frequently prescribed for migraine prophylaxis.
TCAs exert their antidepressant effects by inhibiting presynaptic neurotransmitter reuptake; however, they interact with multiple other receptors, leading to the characteristic manifestations of TCA overdose. In addition, TCAs can block cardiac fast sodium channels, resulting in conduction abnormalities (QRS and QT interval prolongation), which can lead to fatal arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).
Management of TCA poisoning includes supportive care, telemonitoring, intravenous fluids, and benzodiazepines if seizure occurs. In addition, when the QRS interval >100 msec (as in this patient), intravenous sodium bicarbonate should be given to shorten the QRS interval and reduce the risk of fatal arrhythmias. Sodium bicarbonate alkalinizes the plasma, which favors the nonionized (neutral) form of the drug and makes it less accessible to bind to sodium channels. It also increases the extracellular sodium concentration, which helps overcome the sodium channel blockade induced by TCAs.
Amiodarone is an antiarrhythmic medication used to treat ventricular fibrillation, ventricular tachycardia, and wide-complex tachycardias. Although it is not well studied in TCA overdose, amiodarone can cause QTc interval prolongation and is not recommended.
Atropine is indicated for organophosphate toxicity, which also presents with altered mental status typically after exposure to agricultural pesticides. However, signs of cholinergic excess (eg, salivation, urination, diarrhea, bradycardia) would be expected, and QRS interval widening is not typical.
Calcium chloride is indicated for treatment of severe hyperkalemia (in addition to insulin with glucose and beta agonists). It also is indicated for calcium channel blocker (CCB) overdose; CCBs are often used to prevent migraines. Hyperkalemia causes arrhythmias and QRS interval widening but typically produces other ECG findings (eg, peaked T waves). CCB overdose frequently causes hypotension and atrioventricular blocks. However, neither hyperkalemia nor CCB overdose would cause anticholinergic symptoms.
Hemodialysis is used in overdoses to increase the elimination of certain substances (eg salicylates, lithium). However, TCAs have a large volume of distribution, and enhanced elimination has not been shown to be effective.
Tricyclic antidepressant overdose can present with CNS, cardiac, and anticholinergic findings. Sodium bicarbonate is used to treat cardiac toxicity, which is characterized by prolonged QRS duration (>100 msec) and ventricular arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).
••••••••••••••••••••••••••••••••••••••
This patient with chronic pain has altered mental status, hypotension, signs of anticholinergic toxicity (eg, facial flushing, dry mouth), and a prolonged QRS interval. These clinical features suggest tricyclic antidepressant (TCA) poisoning; TCAs are frequently prescribed for migraine prophylaxis.
TCAs exert their antidepressant effects by inhibiting presynaptic neurotransmitter reuptake; however, they interact with multiple other receptors, leading to the characteristic manifestations of TCA overdose. In addition, TCAs can block cardiac fast sodium channels, resulting in conduction abnormalities (QRS and QT interval prolongation), which can lead to fatal arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).
Management of TCA poisoning includes supportive care, telemonitoring, intravenous fluids, and benzodiazepines if seizure occurs. In addition, when the QRS interval >100 msec (as in this patient), intravenous sodium bicarbonate should be given to shorten the QRS interval and reduce the risk of fatal arrhythmias. Sodium bicarbonate alkalinizes the plasma, which favors the nonionized (neutral) form of the drug and makes it less accessible to bind to sodium channels. It also increases the extracellular sodium concentration, which helps overcome the sodium channel blockade induced by TCAs.
Amiodarone is an antiarrhythmic medication used to treat ventricular fibrillation, ventricular tachycardia, and wide-complex tachycardias. Although it is not well studied in TCA overdose, amiodarone can cause QTc interval prolongation and is not recommended.
Atropine is indicated for organophosphate toxicity, which also presents with altered mental status typically after exposure to agricultural pesticides. However, signs of cholinergic excess (eg, salivation, urination, diarrhea, bradycardia) would be expected, and QRS interval widening is not typical.
Calcium chloride is indicated for treatment of severe hyperkalemia (in addition to insulin with glucose and beta agonists). It also is indicated for calcium channel blocker (CCB) overdose; CCBs are often used to prevent migraines. Hyperkalemia causes arrhythmias and QRS interval widening but typically produces other ECG findings (eg, peaked T waves). CCB overdose frequently causes hypotension and atrioventricular blocks. However, neither hyperkalemia nor CCB overdose would cause anticholinergic symptoms.
Hemodialysis is used in overdoses to increase the elimination of certain substances (eg salicylates, lithium). However, TCAs have a large volume of distribution, and enhanced elimination has not been shown to be effective.
Tricyclic antidepressant overdose can present with CNS, cardiac, and anticholinergic findings. Sodium bicarbonate is used to treat cardiac toxicity, which is characterized by prolonged QRS duration (>100 msec) and ventricular arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).
👍7
Case-based MCQ | #MCQ_80
••••••••••••••••••••••••••••••••••••••
A 12-year-old school girl is brought to the emergency department of a tertiary hospital after she collapsed at school. En route to the hospital, she was started on dextrose 5% drip at a rate of 60 ml/minute. On examination after arrival at the emergency department, she has blood pressure of 180/110 mmHg, pulse rate of 50 bpm and respiratory rate of 12 breaths per minute. Doll eye reflex is present. Which one of the following would be the next best step in management ?
A. Arrange for emergency CT scan of the head
B. Stop the dextrose drip
C. Give intravenous steroids
D. Intubate her immediately and start mechanical ventilation
E. Neurosurgical reference
••••••••••••••••••••••••••••••••••••••
A 12-year-old school girl is brought to the emergency department of a tertiary hospital after she collapsed at school. En route to the hospital, she was started on dextrose 5% drip at a rate of 60 ml/minute. On examination after arrival at the emergency department, she has blood pressure of 180/110 mmHg, pulse rate of 50 bpm and respiratory rate of 12 breaths per minute. Doll eye reflex is present. Which one of the following would be the next best step in management ?
A. Arrange for emergency CT scan of the head
B. Stop the dextrose drip
C. Give intravenous steroids
D. Intubate her immediately and start mechanical ventilation
E. Neurosurgical reference
❤6
Case-based MCQ | #MCQ_80
••••••••••••••••••••••••••••••••••••••
Correct Answer Is B
The findings of high blood pressure and bradycardia (Cushing reflex) points towards increased intracranial pressure (ICP) as the most likely cause of such presentation. Cushing reflex (also the vasopressor response, Cushing effect, Cushing phenomenon and Cushing reaction ) is a physiological nervous system response to ICP. Cushing triad is: (1) hypertension, (2) bradycardia and (3) irregular breathing e.g. Cheyne-Stoke. This triad may indicate imminent brain herniation.
Increased ICP is more underpinned by the presence of the ‘doll eye’ sign (movement of the eyes in the same direction as the head) signifying involvement of brainstem, probably due t o increased intracranial pressure.
The raised ICP is very likely to be compromised by dextrose drip which has already been inappropriately started for the patient. Dextrose is rapidly consumed by cells and the remaining free water shifts into the brain extravascular tissue, and results in worsening of the edema, swelling and more increased ICP. For this reason, the dextrose drip should be stopped first as the most important immediate management.
An unconscious patient is not able to maintain airway patency. Furthermore, there is significant risk of aspiration; therefore, the patient should be intubated, but not as the first priority at this stage, considering the fact that the patient is breathing spontaneously and is not hypoxemic (0 2 saturation 95%). The patient should then be taken for CT scan of the head for determination of the likely causes of her problem. Consultation with or referral to the neurosurgery specialist should be arranged.
Intravenous methylprednisolone has shown effective in spinal cord compressions and cases of increased ICP due to tumors and abscesses. If, after neuroimaging, the cause of ICP was found to be an abscess or a tumor, corticosteroids may be considered as a part of management plan.
••••••••••••••••••••••••••••••••••••••
Correct Answer Is B
The findings of high blood pressure and bradycardia (Cushing reflex) points towards increased intracranial pressure (ICP) as the most likely cause of such presentation. Cushing reflex (also the vasopressor response, Cushing effect, Cushing phenomenon and Cushing reaction ) is a physiological nervous system response to ICP. Cushing triad is: (1) hypertension, (2) bradycardia and (3) irregular breathing e.g. Cheyne-Stoke. This triad may indicate imminent brain herniation.
Increased ICP is more underpinned by the presence of the ‘doll eye’ sign (movement of the eyes in the same direction as the head) signifying involvement of brainstem, probably due t o increased intracranial pressure.
The raised ICP is very likely to be compromised by dextrose drip which has already been inappropriately started for the patient. Dextrose is rapidly consumed by cells and the remaining free water shifts into the brain extravascular tissue, and results in worsening of the edema, swelling and more increased ICP. For this reason, the dextrose drip should be stopped first as the most important immediate management.
An unconscious patient is not able to maintain airway patency. Furthermore, there is significant risk of aspiration; therefore, the patient should be intubated, but not as the first priority at this stage, considering the fact that the patient is breathing spontaneously and is not hypoxemic (0 2 saturation 95%). The patient should then be taken for CT scan of the head for determination of the likely causes of her problem. Consultation with or referral to the neurosurgery specialist should be arranged.
Intravenous methylprednisolone has shown effective in spinal cord compressions and cases of increased ICP due to tumors and abscesses. If, after neuroimaging, the cause of ICP was found to be an abscess or a tumor, corticosteroids may be considered as a part of management plan.
Telegram
Case-based MCQ
Enhance Your Medical Expertise with Case Based MCQ – Your Go-To Telegram Channel for Challenging, Real-World MCQs and Continuous Learning.
Admin: @Mohamm_ADs
Admin: @Mohamm_ADs
❤9👍2
Forwarded from EDL Backup Channel
1. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬)
2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦
3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡
4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦)
5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠
6. 🏛
7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪
8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺
9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹
10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧
11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸
12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦
13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷
14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪
15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓
16.
17. 𝗢𝗘𝗧 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡
18. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐
19. 𝗖𝗔𝗥𝗗𝗜𝗢𝗟𝗢𝗚𝗬 𝗖𝗔𝗦𝗘𝗦 🫀
20.
21. 𝗠𝗘𝗗𝗜𝗖𝗖𝗢𝗨𝗡𝗧 - 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗖𝗖𝗢𝗨𝗡𝗧
Please open Telegram to view this post
VIEW IN TELEGRAM
👍3
Case-based MCQ | #MCQ_81
••••••••••••••••••••••••••••••••••••••
An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM. The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis. The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty. She does not know when or if her daughter took the medication. She last saw her daughter the previous evening before going to bed at 10 PM. Her daughter has a history of major depressive disorder but has no known previous suicide attempts. Temperature is 36.1 C, blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min. Pulse oximetry is 98% on room air. On examination, the patient’s clothes are stained with emesis. Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli. The pupils are normal sized, equal, and reactive. Muscle tone and reflexes are normal. Cardiopulmonary and abdominal examinations are normal. There is no evidence of trauma. Which of the following is the best next step in management?
A. Administer activated charcoal
B. Administer cyproheptadine
C. Administer sodium bicarbonate
D. Evaluate for coingestants
E. Obtain serum levels of paroxetine
••••••••••••••••••••••••••••••••••••••
An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM. The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis. The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty. She does not know when or if her daughter took the medication. She last saw her daughter the previous evening before going to bed at 10 PM. Her daughter has a history of major depressive disorder but has no known previous suicide attempts. Temperature is 36.1 C, blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min. Pulse oximetry is 98% on room air. On examination, the patient’s clothes are stained with emesis. Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli. The pupils are normal sized, equal, and reactive. Muscle tone and reflexes are normal. Cardiopulmonary and abdominal examinations are normal. There is no evidence of trauma. Which of the following is the best next step in management?
A. Administer activated charcoal
B. Administer cyproheptadine
C. Administer sodium bicarbonate
D. Evaluate for coingestants
E. Obtain serum levels of paroxetine
👍4❤3
Forwarded from Mediccount - Medical accounts
Please open Telegram to view this post
VIEW IN TELEGRAM
❤1