Educational Objective:

Identify fluid resuscitation as the initial treatment of acute mesenteric ischemia.

Key Point:

The first step of management of acute mesenteric ischemia is fluid resuscitation to correct hypotension and hypovolemia.

Explanation:

This patient likely has acute mesenteric ischemia. He has abdominal pain out of proportion to his physical examination and has significant risk factors of acute mesenteric ischemia. The first step of management of acute mesenteric ischemia is resuscitation, which includes correction of hypotension, hypovolemia, and cardiac arrhythmias. Diagnostic imaging, surgery, or both can follow. Lactic acid is 70% to 100% sensitive but is only 66% specific for acute mesenteric ischemia.

Reference:

Brandt LJ, Feuerstadt P. Intestinal ischemia. In: Feldman M, et al, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 2016:2076-2101.e5.

Educational Objective:

Examine the utility of high-intensity statins.

Key Point:

Statins are used for lowering LDL cholesterol levels. Statins are classified according to their intensity in lowering these levels. When attempting to lower the LDL cholesterol by at least 50%, atorvastatin (40-80 mg) or rosuvastatin (20 mg daily) is an appropriate choice of high-intensity statin.

Explanation:

This patient should be started on atorvastatin based on current guidelines from the American College of Cardiology and American Heart Association. He is younger than 75 years of age and has an LDL value of at least 190 mg/dL, so he should be treated with a high-intensity statin.

The current guidelines classify the intensity of treatment in 3 categories: high, moderate, and low.

High-intensity statins are defined as those that lower LDL cholesterol by at least 50% on average. Atorvastatin (40-80 mg) or rosuvastatin (20 mg daily) would be an appropriate choice of high-intensity statin in this scenario.

Moderate-intensity statins lower LDL cholesterol between 30% and 50%. Lower-dose atorvastatin and rosuvastatin fit this category. Simvastatin (20-40 mg daily), pravastatin (40-80 mg/daily), lovastatin (40 mg/daily), and pitavastatin (2-4 mg/daily) are also members of this category.

Low-intensity statins lower cholesterol by less than 30% and include lower doses of simvastatin, pravastatin, lovastatin, or pitavastatin. This category is not usually recommended for clinical use.

Reference:

Stone NJ, Robinson JG, Lichetenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [Erratum appears in J Am Coll Cardiol. 2014;63(25 pt B):3024-3025]. J Am Coll Cardiol. 2014;63(25 pt B):2889-2934.

Educational Objective:

Characterize the appropriate management of osteoarthritis in the setting of obesity.

Key Point:

The most effective treatment for a patient with osteoarthritis who is obese is weight loss.

Explanation:

For patients with a body mass index greater than 25 kg/m², the highest durability and efficacy of response of the listed options would be weight loss. Hyaluronic acid remains controversial, and the American Academy of Orthopaedic Surgeons has recommended against it due to its lack of efficacy. Injection steroids can provide short- to medium-term relief. Needle lavage of arthritic knees has not been proven effective for osteoarthritis.

References:

Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64:465-474.

Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013;21:571-576.

Patients with a severe head injury should receive seizure prophylaxis because seizures can worsen secondary to brain injury. Further, all patients who are chemically paralyzed should be treated with anticonvulsants because they will not show tonic-clonic seizure activity. Patients with penetrating head injury should receive broad-spectrum antibiotics to prevent infection.

Mannitol should be restricted to patients with intracranial pressure (ICP) monitoring unless they have signs of imminent herniation. Phenobarbital is indicated as a third-line therapy for refractory elevated ICP. Steroids are no longer indicated for traumatic head injuries.

The skull x-ray shows a low-velocity, nonfragmented projectile in the midline.

This 24-year-old man was dead on arrival after a gunshot wound to the head with a high-velocity projectile. (See image below.) The scan shows deep penetration and extensive fragmentation of the projectile.

References:
Vadeboncoeur TF, Bobrow BJ, Merck L. Maximizing survival from severe traumatic brain injury: applying guidelines to clinical practice. Part II. Emerg Med Rep. 2009;30(22):269-278.

Defibrillation and cardioversion work by forcing simultaneous depolarization of all cardiac tissues, thereby synchronizing them.

Ventricular fibrillation on EKG includes the following:

• Chaotic irregular deflections of varying amplitude
• No identifiable P waves, QRS complexes, or T waves
• Rate 150 to 500 per minute
• Amplitude decreases with duration (coarse VF -> fine VF)

N. Garg, M.S. Radeos, Z. Ali, C. Wong, N. Hoang, A.E. Suarez. Identification of Characteristics of Adult Patients in the Emergency Department Who Develop Ventricular Tachycardia or Ventricular Fibrillation During Hospital Stay. Annals of Emergency Medicine, Oct 2013; Vol. 62, Issue 4, S112–S113

Depending on the size of the blast, there will be blast-injury victims as well as contaminated and irradiated patients; however, a large proportion of patients presenting for care will do so for psychological reasons such as fear or concern of potential exposure to radiation. The amount of radioactive material attached to conventional explosives is often small and creates minimal risk. Individuals without symptoms but considerable worry, anxiety, or concern have been described as the "worried well." Unfortunately, it is often very difficult to determine immediately following a radiation incident ("dirty bomb," or otherwise) which patients have been exposed to radiation and which have not been exposed. Terrorists make use of this reality to create mass panic and hysteria and, in turn, overwhelm hospital systems with patients who probably do not need to be there at all. Hospital systems would be well advised to be aware of this and make arrangements for worried-well patients to be cared for away from truly exposed patients.

References:
Colwell CB, Markovchick V. Radiation injuries. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed., 2009:1933-1941.
Rella J. Radiation. In: Nelson LS, et al, eds. Goldfrank's Toxicologic Emergencies. 9th ed., 2011.

Delirium tremens secondary to acute withdrawal of alcohol

Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes. Symptoms most often occur within 72 hours after the last drink. However, they may occur up to 7 to 10 days after the last drink. It is especially common in those who drink 4 to 5 pints of wine or 7 to 8 pints of beer (or 1 pint of “hard” alcohol) every day for several months. Delirium tremens also commonly affects people who have had alcoholism for more than 10 years.

Small red spots with bluish centers located near the posterior molars.

Koplik’s spots are characterized as clustered, white lesions with a red base located on the buccal mucosa opposite the first and second molars. Koplik’s spots appear in the prodromal stage of measles (rubeola).

Acute appendicitis

Both the psoas and obturator signs are associated with acute appendicitis. When the appendix becomes inflamed or ruptured, the blood and pus irritate the psoas and/or obturator muscles, which are both located in the retroperitoneal area. Both muscles are hip flexors and assist with hip movement.

This patient is most likely suffering from laryngitis, which is due to a viral etiology in 90% of cases. But a febrile course of laryngitis that lasts longer than ten days, as was the case for this patient, points towards a bacterial etiology. Multiple different types of bacteria could be the culprits, but they all have in common that they are more likely than viruses to produce endolaryngeal purulent secretions.

Streptococci, diphtheria, and syphilis can all cause acute bacterial laryngitis, with streptococcus being the most common culprit. Leprosy, tuberculosis, and various fungi tend to cause a more chronic form of bacterial laryngitis. Risky sexual behavior, lack of childhood immunizations, and having lived in India (leprosy) are risk factors for a bacterial laryngitis, but only the endolaryngeal purulence points towards the likely PRESENCE of (versus the risk for) a possible bacterial laryngitis.

"Voice abuse" from having a career as a professional singer does not tip the scales towards bacterial laryngitis.

References:
Laryngitis: types, causes, and treatments.. Dworkin JP - Otolaryngol Clin North Am - 01-APR-2008; 41(2): 419-36, ix

Laryngitis--diagnosis and management. Tulunay OE - Otolaryngol Clin North Am - 01-APR-2008; 41(2): 437-51, ix

Cohen & Powderly: Infectious Diseases, 2nd ed. 2004; Chapter 31 - Pharyngitis, Laryngitis and Epiglottitis

An upper gastrointestinal series is the gold standard test for diagnosing volvulus and malrotation.

Malrotation occurs when the intestine does not completely rotate during development. The most common type is failure of the cecum to move to the right lower quadrant. This is associated with failure to form the normal attachment to the abdominal wall.

A volvulus occurs when the small bowel twists around the superior mesenteric artery, causing lack of blood flow and obstruction.

An upper gastrointestinal series can show the malposition of the ligament of Treitz and the "bird’s beak" appearance of obstruction of the duodenum.

Abdominal film can be nonspecific but may show no gas in the abdomen, or it may show a double bubble sign from duodenal obstruction. A barium enema may show malposition of the cecum but is not always sensitive.

Reference:

Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016.

Educational Objective:

Summarize the transmission pattern of African trypanosomiasis in humans.

Key Point:

Human African trypanosomiasis is transmitted through the bite of the tsetse fly.

Explanation:

The endemic region of human African trypanosomiasis, which is also called African sleeping sickness, is limited to several areas of East and West Africa. These organisms are transmitted by the bite of the tsetse fly (Glossina species). The organism travels throughout the bloodstream, invading the lymph nodes and spleen (see Figure). It has a high fatality rate.

Figure. Image courtesy of the Centers for Disease Control and Prevention.Sleeping sickness: biology.

References:

American Academy of Pediatrics. Red Book: Report of the Committee on Infectious Diseases. 31st ed., 2018.

Centers for Disease Control and Prevention. Sleeping sickness: biology. Accessed November 24, 2018.