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1. A 78-year-old patient presents with abdominal pain radiating to the back, bloody stool, and hematemesis with near-syncope. Medical history includes hypertension and surgical grafting for abdominal aortic aneurysm repair. Their vital signs include BP 71/53, P 115, R 16, and T 37.4°C (99.3°F). On examination, a palpable abdominal mass and central abdominal tenderness are noted. What is the most appropriate next step?
- Administer a proton pump inhibitor and a somatostatin analogue
- Request a gastroenterology consultation for urgent endoscopy
- Request a surgery consultation for an emergent surgical procedure
- Transfuse type-specific blood products when available and then reassess
The correct answer is C, Request a surgery consultation for an emergent surgical procedure.
Why is this the correct answer?
When evaluating a patient with progressive GI bleeding following abdominal aortic aneurysm repair, suspicion should be high for aortoenteric fistula. If the patient is unstable, consultation for emergent laparotomy for hemorrhage control and bypass surgery is warranted. A stable patient can undergo CT angiography or endoscopy as part of the workup. Aortoenteric fistulas occur most frequently after a surgical aortic graft (secondary fistula) but can occur after endovascular stenting or from unrepaired aneurysms themselves (primary fistula). As an aneurysm enlarges, it can adhere to and erode the bowel wall (most commonly the duodenum), causing a sentinel bleed that progresses to a massive GI bleed. Erosions can occur by a suture line after endovascular grafting, causing the graft to corrode the surrounding bowel wall. Leakage of bowel contents into the aorta can also lead to abscess formation or infiltration through the aortic wall with subsequent bleeding. The aneurysmal wall might also erode into adjacent venous structures, causing aortovenous fistulae. Aortoenteric fistula has a high mortality rate, and rapid diagnosis is critical.
Why are the other choices wrong?
Proton pump inhibitors (eg, pantoprazole) and somatostatin analogues (eg, octreotide) are treatments for variceal bleeding commonly seen in patients with cirrhosis. Hematemesis is a key feature, with melanotic stool a sign of upper GI bleeding. However, this patient’s presentation is highly concerning for aortoenteric fistula.
Endoscopy is a diagnostic tool for the workup of aortoenteric fistula, but it is not sensitive or specific. It might help exclude other causes of upper GI bleeding, but visualizing a fistula can be difficult. Endoscopy may be useful if variceal bleed is discovered because concomitant endoscopic banding ligation or sclerotherapy can be performed. CT and angiography are also useful and might be obtained more quickly, but no single test offers high sensitivity or specificity.
Blood transfusion is appropriate in the setting of GI bleed, but an unstable patient should be transfused emergently without waiting for type-specific blood products. This is a temporizing measure until the cause of bleeding is found and stopped.
REFERENCES
Colwell CB. Abdominal aortic aneurysm. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 10th ed. Elsevier; 2023:999-1008.
Prince LA, Johnson GA. Aneurysmal disease. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:415-420.
UpToDate article on recognizing and managing aortoenteric fistula, available in full with a subscription
Medscape article on intestinal fistulas
2. An 86-year-old woman presents with a 6-month history of fatigue, lethargy, increasing confusion, constipation, poor appetite, slowed speech, and dyspnea. Her vital signs include BP 105/60, P 55, and T 33.5°C (92.3°F); SpO2 is 91% on room air. She has bilateral pleural effusions and nonpitting peripheral edema. What is the most likely drug-induced etiology of this presentation?
- Amiodarone
- Diltiazem
- Flecainide
- Procainamide
The correct answer is A, Amiodarone.
Why is this the correct answer?
This patient is suffering from myxedema crisis. The iodine in amiodarone is thought to induce hypothyroidism by preventing organification and release of thyroid hormone. Amiodarone is an effective antidysrhythmic, but long-term use can cause a variety of serious and potentially life-threatening adverse effects. These include bradycardia, dysrhythmias, bluish-gray skin discoloration, transaminitis, corneal microdeposits, pulmonary dysfunction, and both hypo- and hyperthyroidism.
Why are the other choices wrong?
Diltiazem is not associated with myxedema crisis. Patients taking diltiazem may develop first-degree, second-degree, or complete heart block.
Flecainide is not associated with myxedema crisis; it is used to maintain sinus rhythm in patients with structurally normal hearts with atrial fibrillation or other supraventricular dysrhythmias. As with many antidysrhythmics, the most significant complications from use are dysrhythmias.
Procainamide has not been associated with myxedema crisis. Long-term procainamide administration has been associated with drug-induced lupus.
REFERENCES
Shields SH, Holland RM, Small B. Pharmacology of antiarrhythmics and antihypertensives. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:123-132.
Idrose AM. Hypothyroidism and myxedema crisis. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1447-1450.
Mazer-Amirshahi M, Nelson LS. Antidysrhythmics. In: Nelson LS, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS, eds. Goldfrank’s Toxicologic Emergencies. 11th ed. McGraw-Hill Education; 2019:865-876.
UpToDate article on amiodarone, available in full with a subscription
3. Which laboratory test result is the gold standard for diagnosing gout?
- Absence of bacteria in aspirate
- High uric acid levels in serum
- Negatively birefringent crystals on aspirate
- WBCs less than 2,000 and PMNs less than 25% on aspirate
The correct answer is C, Negatively birefringent crystals on aspirate.
Why is this the correct answer?
Gout and pseudogout are classified as inflammatory arthritides and are diagnosed by analyzing synovial fluid collected during arthrocentesis. These two can be identified by the level of the cell count along with the presence of crystals, which indicates a crystal-induced synovitis. If the underlying condition is gout, there are negatively birefringent uric acid crystals on aspirate. If it is pseudogout, there is positive birefringence. Patients with gout or pseudogout typically present with acute monoarthritis, most commonly seen in either the great toe or the knee, precipitated by factors such as alcohol consumption, noncompliance of diet, infection, trauma, or other stressors. The treatment of choice for an acute attack starts with NSAIDs or colchicine only in the absence of renal dysfunction. If renal disturbance exists, recent guidelines recommend oral steroids, and a course of narcotic pain medications may be used if necessary.
Why are the other choices wrong?
Although the absence of bacteria on joint aspiration can help make the diagnosis of gout, it is not specific for gout itself and is not the gold standard test result. Only in conjunction with the presence of negative birefringent crystals can the absence of bacteria be used to confirm the diagnosis.
High levels of uric acid in the serum can be found in patients with gout, but the level can also be normal during an acute gout attack. Thus, this finding should not be used to confirm the diagnosis of gout.
A WBC count less than 2,000 and polymorphonuclear leukocytes (PMNs) less than 25% on arthrocentesis indicates the presence of a noninflammatory arthritis, such as osteoarthritis. Gout is in the category of inflammatory arthritides, which have a WBC count between 2,000 and 100,000 and PMNs greater than 50% with a negative culture on arthrocentesis.
REFERENCES
Burton JH, Fortuna TJ. Joints and bursae. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1920-1929.
UpToDate article on diagnosing gout, available in full with a subscription
4. Which finding from the history and physical examination raises the most concern that a patient has an alcohol use disorder?
- Horizontal gaze nystagmus on examination
- Inappropriate sexual behavior after two drinks
- Multiple alcohol-related injuries in the past year
- Slurred speech and an unsteady gait at triage
The correct answer is C, Multiple alcohol-related injuries in the past year.
Why is this the correct answer?
The recurrent use of alcohol in situations where it is physically hazardous is one of the DSM-5 criteria for alcohol use disorder. If a patient continues to drink despite sustaining multiple injuries, it should raise concern that they suffer from this disorder. The other answer choices presented are signs of acute alcohol intoxication but are not necessarily indicative of alcohol addiction. Other criteria for the diagnosis of alcohol use disorder include tolerance, in which the individual requires increasing amounts of alcohol to achieve the same effect, and withdrawal. Patients with alcohol use disorder may continue to drink despite negative social and professional consequences and failure to achieve major role obligations at home and work. They might also crave alcohol and spend prolonged amounts of time and effort obtaining alcohol. Alcohol use disorder can be categorized as mild, moderate, or severe depending on the number of symptoms present. As far as an emergency department intervention, it has been shown that a brief negotiated interview with the patient summarizing options to help stop drinking is successful in reducing hazard-related drinking.
Why are the other choices wrong?
Involuntary jerking of the eyeballs (nystagmus) becomes more pronounced as persons become intoxicated, and the horizontal gaze nystagmus test is commonly used to determine whether someone has acute alcohol intoxication. However, it does not indicate whether a person has an alcohol use disorder.
Many people exhibit problematic psychological or behavior changes after drinking alcohol, such as inappropriate sexual behavior, labile mood, poor judgment, and aggressive behavior. However, these behaviors alone do not indicate alcohol use disorder.
Other signs and symptoms of alcohol intoxication include slurred speech, unsteady gait, coma or stupor, incoordination, and memory impairment. However, these behaviors alone do not indicate alcohol use disorder.
REFERENCES
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association; 2013.
Hawk , Samuels EA, Weiner SG, D'Onofrio G, Bernstein E. Substance use disorders. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1959-1966.
ACEP policy statement on alcohol screening in the emergency department
UpToDate article on risky drinking and alcohol use disorder, available in full with a subscription
5. A 74-year-old woman presents with an anterior shoulder dislocation after a fall. Her vital signs include BP 86/40 and P 110. Intravenous access is established, and a fluid bolus results in mild improvement in her blood pressure. She has no allergies. Which medication is preferred for procedural sedation to reduce the dislocation?
- Fentanyl
- Ketamine
- Midazolam
- Propofol
The correct answer is B, Ketamine.
Why is this the correct answer?
Ketamine is a dissociative anesthetic that is being used more often for procedural sedation. Ketamine has been shown in some cases to cause hypertension, so it might be preferred in patients with hypotension, such as this patient. Nausea and vomiting side effects can be abated by presedation antiemetic therapy. Other side effects of ketamine reflect its sympathomimetic properties, including laryngospasm, apnea, angina, and congestive heart failure. Traditionally, ketamine has been contraindicated in patients with increased intracranial pressure and increased intraocular pressure. However, recent evidence calls into question the relationship of ketamine and increased intracranial and intraocular pressures.
Why are the other choices wrong?
Many different medications and combinations can be used for procedural sedation. However, in the setting of hypotension, many of these medications can cause a further drop in blood pressure. Fentanyl provides analgesia without sedation and is frequently used for pain control because of its brief duration, rapid onset, easy reversibility with naloxone, and lack of histamine release. Certain side effects, such as respiratory depression, can be easily reversed with an opioid antagonist. A rare side effect of fentanyl is chest wall rigidity, which can be reversed with naloxone, positive-pressure ventilation, or a combination thereof.
Benzodiazepines such as midazolam are often used in procedural sedation and provide the additional benefit of amnestic properties. However, benzodiazepines provide no analgesia and can cause hypotension, respiratory depression, and paradoxical excitement.
Common side effects of propofol include hypotension and respiratory depression, so this medication might worsen this patient’s hypotension and should be avoided. Additionally, propofol should not be used in patients with an egg or soy allergy.
REFERENCES
Naples RM, Ufberg JW. Management of common dislocations. In: Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019:980-1026.
Bjoernsen L, Ebinger A. Shoulder and humerus injuries. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1821-1836.
ACEP Clinical Policy on procedural sedation
UpToDate article on procedural sedation, available in full with a subscription