The Challenge Thursday, November 17th

Your ED is extremely busy, with an average 5-hour wait when ZT, a 26yo male (61kg) with a past medical history of sickle cell disease presents reporting 10/10 pain. He says this feels like his previous episodes of pain crisis. He has taken 2 doses of his home 10mg oxycodone tablets, but with no relief. The triage nurse asks what the most appropriate course of action is, as she doesn’t want to “waste a room” since ZT seems fine and is on FaceTime with a friend. Which is the most appropriate response to the triage nurse?

A 62-year-old male with a history of chronic kidney disease (CKD), depression, and recently diagnosed squamous cell carcinoma presents to the emergency department with with fatigue, weakness, and constipation. His presenting vital signs include BP 110/62 mm Hg, HR 110 beats/min, RR 26 breaths/min, and temperature 38.9 C. His lab test results include Na 145mEq/L, K+ 5.1 mEq/L, Cl 101 mEq/L, CO2 18 mEq/L, SCr 1.2 mg/dL (baseline 1.0 mg/dL), BUN 15 mg/dL, calcium 13.4 mg/dl, and glucose 126 mg/dL. The patient was started on 0.9% sodium chloride infusion and the team with requesting on how to treat this patient hypercalcemia of malignancy. Which is the best therapy to add next for this patient’s hypercalcemia?

A 42-year-old man with von Willebrand disease presents to the emergency department with a fall to his side with and open fracture to his elbow. Vital signs include a heart rate of 90 bpm and a blood pressure of 115/75 mm Hg. Laboratory workup is notable for a hemoglobin of 12.0 g/dL, platelets of 150,000/microliter, and an international normalized ratio of 1.0. The trauma team consults orthopedics, and they will not have to take him to the OR. What is the most appropriate treatment to address this patient’s bleeding?

A 75-year-old female presents to the hospital complaining of shortness of breath and requiring 3-4 pillow to be able to sleep at night, which has been progressively worsening over the last week. She has a past medical history of hypertension and cancer. She states that he was recently started on a new chemotherapy agent one month ago for a newly diagnosed lymphoma. Which of the following agents was this patient most likely started on by his care provider?

What is the cutoff required for the diagnosis of early-onset neonatal sepsis?

TH is a 62yo male who presents to the ED with a 3-day history of weakness, fever, and neck stiffness. He has a past medical history of hypertension for which he takes lisinopril and reports no allergies. In triage his temperature is 101.3°F, HR 102, RR 21, BP 114/72, O2 saturation 98% on room air. CBC and BMP are significant for a WBC of 11.8 and lactate of 3.7. The physician suspects meningitis and prepares for a lumbar puncture. Which of the following is the most appropriate recommendation for empiric therapy in TH?

A 47 -year-old man with a past medical history of hypertension presents to the emergency department (ED) with the chief complaints of fever, chills, and abdominal pain. Pertinent vital signs on admission are as follows: blood pressure 110/78 mm Hg, heart rate 115 beats/minute, respiratory rate 16 breaths/minute, temperature 100.3°F, and oxygen saturation of 97% on room air. The patient’s workup is suspicious for sepsis with moderate risk intra-abdominal infection and is currently being admitted to the medical wards. According to the patient’s medical record, he has not allergies and currently taking amlodipine 10 mg by mouth daily. Which of the following is the most appropriate antibiotic therapy for this patient?

72 yo F PMHx significant for HTN, atrial fibrillation (on apixaban), HF (EF 30%), presents to the ED after a motor vehicle collision (car vs. pole). In the trauma bay she is mentating well and her vitals are as follows: HR 90, BP 88/62, RR 20, 95% O2 saturation on room air. FAST exam positive for intraperitoneal fluid, concerning for hemorrhage secondary to a blunt injury.  Which intervention should be prioritized for this patient?

A 45-year-old man was the driver in a motor vehicle collision. The patient is unable to offer a medical history during the initial presentation. His temperature is 97.6°F (36.4°C), blood pressure is 104/74 mmHg, pulse is 150/min, respirations are 12/min, and oxygen saturation is 98% of room air. During the GCS exam, he does not open his eyes, contracts in pain and makes unintelligible noises. He has obvious signs of trauma to his chest and abdomen. His abdomen is distended and markedly tender to palpation. He also has an obvious open deformity of his left femur. What is the best initial step in management?

A 72 yo F with PMHx of atrial fibrillation (not on anticoagulation), hypertension is brought to the ED after sustaining a high speed (50-60 mph) MVC as the front passenger with airbag deployment. Initial exam yields a GCS of 5, concerning for severe TBI. The patient undergoes RSI with etomidate and succinylcholine and a bolt is placed for ICP monitoring. Current vitals are as follows: RR 18, HR 88 bpm, BP 110/76, ICP 19, temperature 37 degrees Celsius. Which intervention is inappropriate at this time?

A 22-year-old man presents to the ER from a community hospital where he was diagnosed with a C3-C4 fracture and incomplete spinal cord injury (SCi). The fracture has been reduced. Which is the most appropriate statement for initiating high-dose methylprednisolone therapy for this patient’s SCI?

A 62 year old male, C.W. is brought in by ambulance for complaints of chest pain and a feeling that his heart is racing. As he enters the ED he suddenly goes unresponsive. You pull up the patient’s chart and find he has a past medical history of hypertension, hyperlipidemia, and chronic kidney disease which he does to dialysis Mon/Wed/Fri. His wife arrives with him and states “he hasn’t been feeling well and has missed 2 dialysis sessions.” An EKG is completed and it has T wave inversions. Which of the following H’s and T’s could be causing the patient to be unresponsive?

A 45 year old woman, B.L., is brought in by ambulance to the ED. She is in cardiac arrest and her rhythm is asystole. Her sister states they were walking around the neighborhood when she suddenly collapsed and went unresponsive. She recently had surgery on her foot about a month ago and this was the first day she felt well enough to take a short walk. The nurses are unable to get any vital signs on the patient and CPR is started. The ED physician is concerned for a pulmonary embolism and wants to give a dose of alteplase. The patient is 70 kg. Which of the following is the correct dose of alteplase to give?

RK is a 59yo female (101kg) who is brought to the ED as a post-cardiac arrest patient. Paramedics report she has an extensive cardiac history with previous CABG. She was eating dinner with her family when she suddenly grabbed her chest and lost consciousness. Her daughter is in nursing school and immediately began performing CPR. Once EMS arrived, they noted the patient to be in ventricular fibrillation, and obtained ROSC after 1 shock. Their post-ROSC EKG shows a ST segment elevation in the lateral leads, with reciprocal changes in the septal leads, which is confirmed with in-house EKG prompting the ED physician to call a STEMI alert. Upon presentation RK looks visibly ill, she is pale and diaphoretic, HR 98, BP 104/52, RR 24, O₂ saturation 88% on 15L non-rebreather. The ED team is concerned that she may go into cardiac arrest again. Unfortunately, the cath lab calls back saying that they have cases ongoing in both of their rooms, so there will be a delay in taking RK up. Due to her critical presentation, the ED physician decides to proceed with alteplase administration due to the delay in catheterization. Which of the following is the most appropriate dosing of alteplase for RK?

47-year-old male presenting to the emergency department (ED) via emergency medical services (EMS) transport from home for altered mental status and new onset palpitations. The patient has a past medical history of hypertension taking amlodipine. Her presenting vital signs include BP 120/62 mm Hg, HR 161 beats/min, RR 21 breaths/min, and temperature 38.9oC.  A 12-lead ECG reveals a wide complex tachycardia with a irregular rhythm with prolonged QT internal that is identified as polyomorphic ventricular tachycardia. Which of the following interventions would be the best initial option for acute management in this patient?