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This patient is suffering from respiratory distress and impending respiratory failure. Rocuronium is a nondepolarizing paralytic agent; succinylcholine is a depolarizing paralytic agent. One side effect of depolarizing agents is an increase in serum potassium. On average, succinylcholine raises the serum potassium by about 0.0–0.5 mEq. But in patients with certain underlying conditions, the rise in serum potassium can be more dramatic (1.0–2.0 mEq), leading to hyperkalemic dysrhythmias. These conditions include burns, denervation injuries, crush injuries, myopathies, and prolonged immobility. The more dramatic rise results from the upregulation of acetylcholine receptors at the neuromuscular junction, which takes 5 days to develop. Thus in patients with an acute burn, acute crush injury, or acute denervation, the risk of succinylcholine-induced hyperkalemia is minor. The dose of succinylcholine is 1.5 mg/kg and rocuronium is 1.0 mg/kg. Rocuronium and other nondepolarizing agents do not cause a rise in serum potassium.

In this patient, succinylcholine (C and D) would be contraindicated because the patient has suffered a denervation injury (CVA) and is bed bound. Rocuronium or another nondepolarizing agent would be a more appropriate drug. Etomidate, a short-acting hypnotic agent, should be dosed at 0.3 mg/kg during rapid-sequence intubation. A dose of 0.1 mg/kg of etomidate (B) can be used for procedural sedation.

This intubated patient began to decompensate shortly after returning from the radiology suite. It is essential to establish a quick and logical approach to the unstable patient on mechanical ventilation when the ventilator alarms are sounding and the patient is hemodynamically compromised. The first critical action is to disconnect the patient from the ventilator. Removing the ventilator from the equation limits the number of variables in solving this life-threatening challenge and immediately eliminates it as a primary culprit.

The patient may be decompensating from a pulmonary embolism, but until more basic causes are ruled out, thrombolytics (A) should not be administered. A chest radiograph (C) can aid in determining why the patient is decompensating, but it should be obtained after the patient is disconnected from the ventilator. In the absence of clear signs of tension pneumothorax (decreased breath sounds, tracheal deviation, JVD), needle thoracostomy (D) should not be performed empirically.

Endotracheal intubation occurs in approximately 2% of all asthma exacerbations and about 10-30% of patients requiring intensive care admissions. Management of patients with severe asthma who are mechanically ventilated is challenging and therapies aimed at avoiding intubation should be employed. Magnesium sulfate administered intravenously at doses of 2 to 3 g promotes bronchodilation and leads to decreased rates of intubation in the severe asthmatic. Noninvasive ventilation with BiPAP is another therapy shown to decrease rates of intubation in these patients.

Heliox (A) therapy has been employed as a means to improve the administration of medication into the distal branches of the airway. Heliox is a mixture of helium and oxygen, which in combination has a decreased density compared with air and allows for more laminar flow into the distal airway. Given the mixture of oxygen with helium, 100% oxygen cannot be delivered and this therapy is cautioned in severely hypoxemic patients. In theory, the use of heliox will improve the effectiveness of medication delivery and effect and potentially avoid intubation although no data has linked its use with decreased rates of hospitalization or intubation. Inhaled corticosteroids (B) have shown benefit when used either alone or in combination with systemic corticosteroids presumably through their anti-inflammatory effects locally within the airway tissue. Steroids typically begin to have effect within hours of their treatment. Inhaled corticosteroids are associated with decreased rates of hospital admission. Leukotriene inhibitors like montelukast (D) are useful in asthmatics due to overproduction of leukotrienes by these patients leading to increased airway inflammation. Patients who receive oral montelukast have more improvement of peak flow the morning after admission, but its use has not decreased rates of hospital admission or intubation.

Myoclonus is a common side effect after administration of etomidate in procedural sedation. Etomidate is a amnestic agent that is commonly used in rapid sequence intubation and for conscious sedation. The onset of action of an intravenous dose of etomidate is roughly 30 seconds and the drug has a short half-life leading to an awake and alert patient within 5-15 minutes of drug discontinuation. The primary adverse effects of the drug are myoclonus, nausea, vomiting and respiratory depression. The myoclonus is benign but can be mistaken for seizure activity and can make certain procedures more difficult (e.g. orthopedic reduction).

Fentanyl (B) is an opioid used for pain control in sedation and can cause respiratory depression. Midazolam (C), a benzodiazipine, and propofol (D) are both potent sedative agents that can cause respiratory depression and hypotension. Propofol very rarely can cause myoclonus, but is much less likely than etomidate to have this effect

The Mallampati score was developed in order to predict difficulty of orotracheal intubation based on the structures visualized upon inspection of the oropharynx. In order to perform the Mallampati evaluation, the patient is seated with the neck extended. The patient is asked to open the mouth and protrude the tongue, with or without phonating. Complete visualization of the oropharynx including the tonsillar pillars is a Class I view. Class I and II predict adequate oral access for laryngoscopy. Class III predicts only moderate access and Class IV predicts a significant difficulty. Research has shown that the Mallampati score is a valid predictor of difficult laryngoscopy. In a Class III view demonstrated above, the soft palate and base of the uvula is visible.

A Class I (A) view allows full visualization of the soft palate, uvula, fauces and tonsillar pillars. A Class II (B) view shows the soft palate, uvula and fauces but no tonsillar pillars. A Class IV (D) view only shows the hard palate and is most predictive of a difficult intubation.

A needle cricothyrotomy is a recommended last resort emergency department procedure for complete upper airway obstruction. Very little literature supports its use or safety due to the exceedingly rare circumstances in which it should be used. To perform a needle cricothyrotomy place a towel under the shoulders extending the neck and forcing the trachea anteriorly and palpate for the cricothyroid membrane. This may be difficult to find in small children and you may need to cannulate the proximal trachea instead. Place a finger and thumb on either side to stabilize the trachea and cannulate it at a 30° angle directed caudally with a 14G over-the-needle catheter. Aspirate air into a 3- or 5-mL syringe to ensure entry into the trachea. Without firm cartilaginous rings the trachea collapses easily making it difficult not to penetrate the back wall of the trachea. Once you aspirate air, gently slide the catheter off the needle and attach the 3.0 mm ETT adapter to which you can attach a bag-valve mask. You will need significant pressure to overcome the resistance of the small diameter catheter, well above the limits of a regular pop-off valve that must be disabled. Watch and wait for chest fall between each breath which may be significantly delayed due to the small diameter catheter. Hold the catheter at all times even after it has been secured. Remember this is a temporizing measure only to provide oxygenation for a brief period while additional resources are summoned. Jet ventilation has also been defended but has been shown to cause barotrauma.

With a 5 mL syringe, 3.0 mm ETT adapter, and 20G over-the-needle catheter (B) you may not be able to provide sufficient oxygen; use the largest bore needle available. A 5 mL syringe, 5.0 mm ETT adapter, and 14G over-the-needle catheter (C) or a 5 mL syringe, 5.0 mm ETT adapter, and 20G over-the-needle catheter (D) do not have the correct adapter size that will fit your catheter.

*Alternatively, a 3 mL luer-lock syringe is compatible with a 7.0 mm ET tube, which you can connect together and attach to your angiocath

Asthma results in over 1.5 million emergency department visits yearly, and while the vast majority of these patients are treated and subsequently discharged home, a small percentage have severe symptoms that require endotracheal intubation and mechanical ventilation. Indications for intubation are based on clinical findings and include depressed mental status, declining respiratory rate, worsening hypercapnia and progressive hypoxia despite adequate treatment. Rapid sequence intubation (RSI) is the preferred method of intubation. Ketamine is the induction agent of choice when intubating severe asthmatics. A dissociative anesthetic, ketamine has potent bronchodilator effects, making it an ideal choice. It acts as a smooth muscle dilator, increases circulating catecholamines and does not cause histamine release. Ketamine (1-2 mg/kg IV) should be given followed by succinylcholine (1.5 mg/kg) or a competitive neuromuscular blocking agent such as rocuronium.

Etomidate (A) is a sedative-hypnotic frequently used for RSI and is a good choice in hypotensive patients as it the most hemodynamically neutral of the sedative agents used. However, it does not have any bronchodilator effects making ketamine the better choice. Midazolam (C) is a rapidly acting benzodiazepine that can be used for RSI but it can cause moderate hypotension so it would not be a good choice in this case. Propofol (D) is a lipid-soluble alkylphenol derivative that acts at the GABA receptor to cause sedation and amnesia. It also has some bronchodilator effects making it a good choice in asthmatic patients. However, it can also cause hypotension and, therefore, would not be the best choice in this case.

Bilevel positive airway pressure (BiPAP) is a method of noninvasive positive-pressure ventilation that uses two different pressure settings, one during inspiration and one during expiration. The inspiratory pressure is triggered when the patient takes a breath. Both continuous positive airway pressure (CPAP) and BiPAP can be used in patients with acute cardiogenic pulmonary edema and help avoid the need for endotracheal intubation. CPAP and BiPAP reduce the work of breathing, increase inflation of alveoli, and improve compliance. They also decrease preload, thus offsetting ventricular filling pressures.

Albuterol/ipratropium (B) is used in the treatment of asthma. It has not been shown to reduce rates of intubation in pulmonary edema. High-flow nasal cannula oxygen (C) is an emerging method of respiratory support for patients with severe dyspnea. In the pediatric patient with bronchiolitis, it has been shown to improve oxygenation and reduce the need for intensive care unit admission. But it has not been specifically evaluated in the management of adults with acute cardiogenic pulmonary edema. A non-rebreather mask (D) delivers oxygen but does not provide significant positive pressure. Therefore, it does not have the same beneficial effects that BiPAP or CPAP has in patients with pulmonary edema.

The term permissive hypercapnia defines a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure. The aim of permissive hypercapnia is to minimize lung damage during mechanical ventilation; its limitation is the resulting hypoventilation and carbon dioxide (CO2) retention.

The major concern for mechanically ventilated patients with obstructive airway disease is dynamic hyperinflation (also known as auto-PEEP, intrinsic PEEP, breath stacking, or air trapping). This condition occurs when gas becomes trapped in the lungs during mechanical ventilation. The air trapping is caused by inadequate time for exhalation allowing for delivery of the next breath before the patient has time to completely exhale. This leads to increased alveolar pressures, decreased venous return, and decreased cardiac output ultimately leading to hemodynamic instability. Auto-PEEP can be detected on the ventilator waveform because the flow will not return to zero before the next breath.

Strategies to avoid auto-PEEP would be any factor that decreases the I:E ratio which include decreasing the minute-ventilation (respiratory rate and/or tidal volume), or increasing the inspiratory flow rate (the standard flow rate is 60 L/min, this can be increased up to 80-100 L/min). These factors allow more time for the patient to complete exhalation minimizing the risk of hyperinflation. In severe cases, deep sedation and paralysis may be necessary to improve ventilator synchrony and avoid auto-PEEP.

Rates of asthma mortality have decreased over time. Mortality rates are higher in women and African-Americans. Assessing risk factors related to increased rates of mortality are important to identify in the evaluation of a patient with an acute exacerbation. A history of prior intubations is associated with increased mortality in patients with an acute asthma exacerbation. Other factors include:

History of hospitalization at age 18 (A), Recent use of nebulized albuterol (B), and peak flow 70% predicted (C) are not predictive of increased mortality as isolated risk factors. A history of hospitalization at age 18 does suggest that the patient has had an episode of severe asthma in the past, but hospitalizations are predictive within the last year or month. Recent use of corticosteroids not albuterol is associated with increased risk of mortality. During an acute exacerbation, there is impairment of expiratory flow. A peak flow 70% predicted suggests mild airway obstruction but is not an independent predictor of mortality. Some studies have linked an increasing severity score of asthma with mortality, however a severe asthma exacerbation is marked by a PEF <40%

Schizoid personality disorder is classified as a cluster A personality disorder. This cluster describes patients with odd and eccentric behavior and includes paranoid personality disorder and schizotypal personality disorder. Patients with schizoid personality disorder generally prefer to be left alone. They do not enjoy engaging in social or sexual relationships or interactions. They are markedly detached from society, introverted, and primarily choose solitary activities or hobbies. They may be indifferent to praise or criticism and appear withdrawn or aloof. Schizoid patients are rarely seen in clinical practice. Patients with cluster A disorders may be difficult to treat because of an intrinsic distrust or suspicion of others. They may express resistance in engaging, but it is important to be clear in explaining management intentions without becoming overly involved in their personal lives. It is also important to remain professional, direct, and empathetic toward them and not to react emotionally to their odd, inappropriate or dramatic behavior.

Antisocial personality disorder (A) is a cluster B disorder characterized by selfishness, impulsivity, promiscuity, callousness, disregard for rules or other people, pervasive deception and lying, lack of remorse, and difficulty learning from prior experiences. Patients are commonly in trouble with the law. Borderline personality disorder (B) is also a cluster B disorder and is characterized by a lack of self-control, violence, aggression, and having unstable relationships (e.g., frequent break ups). Drug abuse and suicide attempts are very common in borderline individuals. Schizoaffective disorder (C) is not a personality disorder, but rather a condition on the spectrum schizophrenia-like disorders. It is characterized by the presence of delusions, hallucinations, disorganized speech, catatonia or grossly disorganized behavior, along with mood disturbance such as mania or major depression.

IM haloperidol
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient unable to follow commands, rapid sedation is indicated. Once the patient is calm, a focused medical assessment can be safely performed.

A. CT head, basic blood work, urine toxicology screen
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient, verbal deescalation and, if necessary, rapid sedation with an antipsychotic may be necessary. Verbal deescalation has failed in this patient, and blood testing and imaging are unlikely to be successful at this time.

C. Sublingual olanzapine
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. While sublingual olanzapine is a great option in a cooperative patient, this patient is not following commands. In an acutely agitated and unncooperative patient without IV access, intramuscular administration is the safest and most effective.

D. IV midazolam
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In this uncooperative patient where verbal deescalation has failed, rapid sedation is most appropriate. Benzodiazepines would be an option, but starting a peripheral IV would be difficult in this aggressive patient.

Diphenhydramine IM
The patient in the above question is demonstrating signs of an acute dystonic reaction. Acute dystonic reactions can occur at any point during long-term or short-term antipsychotic therapy. They are more common with typical antipsychotics such as haloperidol. Symptoms include involuntary contraction of muscle groups commonly seen in the neck (torticollis), tongue (buccolingual crisis), and eyes (oculogyric crisis). Treatment of acute dystonic reaction includes IM diphenhydramine or IM benztropine. After receiving one of these muscular agents, patient should receive the same medication in oral form for 48-72 hours to prevent recurrence. Source
Pringsheim T, Doja A, Belanger S, Patten S. Treatment recommendations for extrapyramidal side effects associated with second-generation antipsychotic use in children and youth. Paediatr Child Health. 2011;16(9):590-8.
PMC3223903

A. Benztropine PO (incorrect)
Benztropine can also be used to treat dystonic reactions; however, the appropriate route of administration is IM followed by subsequent PO dosing for 48-72 hours

B. Dantrolene IV (incorrect)
Dantrolene would be more appropriate for the treatment of malignant hyperthermia or neuroleptic malignant syndrome

D. Lorazepam IM (incorrect)
Ativan is an agent that can be effectively used to treat mild agitation or akithesia. It is not the appropriate therapy for dystonic reactions

Certain risk factors have been identified for trafficking. A tattoo that the patient is reluctant to discuss is a potential red flag. Some traffickers brand their victims.

Trafficking should be considered if the individual is traveling with an older companion (B) who is not a guardian. Those trafficked into commercial sex are overly familiar with sexual language and practices (D). Physicians should be suspicious when the accompanying person tries to answer all the questions and insists on being present at all times (C).

Lorazepam
The correct answer is benzodiazepines. For sympathomimetic toxidromes, the most efficacious medicines to reduce blood pressure/tachycardia/hyperthermia are benzos. Beta blockers are contraindicated as they lead to unopposed alpha activity. Phentolamine is a difficult medicine to titrate.

B. Clonidine
This patient likely has a sympathomimetic toxidrome. Treatment of choice is a benzodiazepine, not clonidine.

C. Labetolol
Beta blockers are contraindicated in cocaine toxicity

D. Phentolamine
Rarely used and difficult to titrate

Phencyclidine (PCP) was initially developed for use as a general anesthetic. However, frequent emergent reactions led to its discontinuation in the therapeutic setting. PCP is well absorbed from any mucous membrane and can also be smoked. The drug affects many receptors and therefore causes a broad spectrum of clinical findings. In most cases, the sympathomimetic effects predominate and patients are agitated, exhibiting both bizarre and violent behavior. Patients may, however, demonstrate catatonic features. Nystagmus is often present and may be horizontal, vertical or rotatory. The patient’s hemodynamic status is most often consistent with a sympathomimetic picture with hypertension, tachycardia and possibly hyperthermia.

Crystal methamphetamine (A) is an amphetamine causing release of presynaptic catecholamines. Most commonly amphetamines are ingested, but can be crushed and injected as well. Patients develop typical sympathomimetic effects. With crystal methamphetamine, patients may also become paranoid with delusions. Its use has also been associated with engaging in high-risk behavior, specifically sexual in the men who have sex with men community. Gamma hydroxybutyrate (GHB) (B) is a popular recreational drug classified as a sedative/hypnotic. When ingested it produces a euphoria that is popular at rave parties. Particularly when mixed with ethanol, GHB has a marked CNS depressive effect often leading to respiratory depression requiring transient intubation. It has also been implicated as a date rape drug due to its sedative and amnestic effects. Lysergic acid diethylamine (LSD) (C) is a potent psychoactive drug taken orally as a tablet, liquid, powder, gelatin square or on a sheet of blotter paper. The medication is a hallucinogen with serotonin-like characteristics. Patients go on a “trip” during which perception between the user and environment are distorted. Patients may have an acute panic reaction after taking LSD.

This patient has gamma-hydroxybutyric acid (GHB) intoxication. GHB is an analogue of the inhibitory neurotransmitter GABA. It has been commonly used and abused by bodybuilders because of its anabolic effects. GHB also has euphoric effects, which has caused it to gain popularity as a club drug. Its sedative and amnestic effects have caused GHB to be implicated in cases of drug-facilitated sexual assault (“date rape”). Clinically, GHB overdose can range from euphoria to depressed mental status with or without coma. Vital sign abnormalities such as hypothermia, bradycardia, and hypotension may be present. U waves can be seen on ECG. Pupils are small and minimally responsive to light. Respiratory depression may occur, but—despite a comatose appearance—most GHB intoxicated patients maintain adequate ventilation. Effects of GHB overdose generally resolve within six to eight hours. The classic presentation of GHB overdose is a comatose patient who requires intubation then has an abrupt awakening. Care for GHB intoxication is largely supportive and includes benzodiazepines for agitation, fluid resuscitation, and keeping the patient in a safe environment.

Midazolam (B) is a short-acting benzodiazepine. Benzodiazepines are generally not found in bodybuilding supplements and rarely cause hypotension or bradycardia when ingested alone. The patient in this scenario has slow respirations, coma, and small pupils but does not respond to naloxone, making opioid intoxication (C) less likely. Opioids are also generally not found in bodybuilding supplements. Phenobarbital (D) is a long-acting barbiturate. Barbiturates can cause significant cardiovascular and central nervous system depression; however, given its long duration of action, it is unlikely that the patient would abruptly regain consciousness after six hours.

The boy has signs and symptoms consistent with opioid ingestion. Methadone ingestion can manifest with the classic opioid toxidrome of respiratory depression, sedation, and miosis. Signs of more severe toxicity can include bradycardia, hypotension, and hypothermia. Methadone has been associated with a prolonged QTc interval and risk of torsades de pointes. Patients with significant respiratory or CNS depression should be treated with naloxone, which is a mu receptor antagonist. Because the half-life of methadone is longer than naloxone, patients can require multiple doses of naloxone. Also, serial ECGs are needed to monitor for the development of a prolonged QTc interval. If a patient does develop a prolonged QTc, management includes close cardiac monitoring, repletion of electrolytes, and having magnesium readily available should the patient develop torsades de pointes.

Clonidine (A) toxicity manifests as lethargy, miosis, and bradycardia. Although, findings may be similar to opioid overdose, QTc interval prolongation and torsades de pointes are typically only seen with opioid overdose. Propanolol (C) toxicity causes bradycardia and hypotension that typically develops within six hours of ingestion. Heart block and hypoglycemia may also be seen. Clinical manifestations of salicylate (D) toxicity include nausea, vomiting, diaphoresis, and tinnitus. Moderate cases can manifest as tachypnea, tachycardia, and altered mental status.

Serotonin syndrome occurs when there is an excess of systemic serotonin, usually due to a combination of medications, in this case fluoxetine and phenelzine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that has a long half-life and active metabolites. Phenelzine is a monamine oxidase inhibitor (MAOI) that inhibits serotonin breakdown. Because of fluoxetine’s long half-life and the consequent risk of serotonin syndrome, a 6-week washout period is recommended postdiscontinuation before starting an MAOI. Serotonin syndrome is characterized by altered mental status, hyperreflexia, clonus, rigidity, and autonomic instability. Treatment includes removing the offending drugs, cooling measures, benzodiazepines, fluid resuscitation, and cyproheptadine, a serotonin antagonist.

Acute dystonic reactions (A) result from administration of dopaminergic-blocking agents (especially antipsychotics and some antiemetics) and include torticollis, akathisia, and pseudoparkinsonism. Unlike serotonin syndrome, altered mental status and autonomic instability do not occur with acute dystonic reactions. Hypertensive crisis (B) can occur in patients taking MAOIs, usually in the context of eating foods that are high in tyramine; however, altered mental status, hyperthermia, and movement disorders are not as common in this setting. Neuroleptic malignant syndrome (NMS) (C) occurs in the setting of antipsychotic medication administration. The onset is often more insidious then serotonin syndrome but can be difficult to distinguish because both can present with autonomic instability, hyperthermia, altered consciousness, and movement disorders. NMS is more commonly associated with bradykinesia and lead pipe rigidity. Patients with serotonin syndrome tend to have more agitation and myoclonus/hyperreflexia. A careful medication history can also help to distinguish the etiology.

Tricyclic antidepressant (TCA) overdose initially manifests with anticholinergic symptoms such as sinus tachycardia and hypertension and can progress to seizures, coma and cardiovascular collapse. A dose greater than 10 mg/kg or 1000 mg in an adult should be considered life threatening. Severe lactic acidosis impairs myocardial sodium conduction leading to hypotension, dysrhythmias and ultimately cardiac arrest. Changes on ECG include QRS prolongation (greater than 100 msec), PR prolongation and rightward shift of the terminal 40-msec QRS vector. Treatment begins with assessment of airway and breathing. If intubated, hyperventilation will aid in reversing the acidosis. If the QRS is greater than 100 msec and the patient is symptomatic with hypotension or a dysrhythmia, or if the patient is acidemic, then intravenous sodium bicarbonate should be administered. Sodium bicarbonate produces an alkaline pH and provides a sodium load to aid conductance through the myocardial sodium fast channels that are blocked by the TCA. Sodium bicarbonate is administered by IV boluses of 1 to 2 mEq/kg until the QRS narrows or until the pH increases to 7.50-7.55. Once this is achieved, then a continuous infusion can be maintained by adding three ampules of 8.4% sodium bicarbonate (50 mEq/ampule) to one liter of 5% dextrose in water. The initial infusion rate mirrors that of the patient’s usual maintenance rate of intravenous fluids and should be maintained for 4 to 6 hours.

Hypertonic sodium chloride (A) is considered treatment of hypotension, acidemia and widened QRS interval that is refractory to treatment with sodium bicarbonate and fluid resuscitation. Intralipid (B) may be considered for refractory hypotension due lipophilic drug overdose, including TCA overdose, but is not first line. Vasopressors, such as norepinephrine (C) or dopamine, may be considered in persistently unstable patients after sodium bicarbonate therapy is maximized or no longer being tolerated.

Cholesteatoma is a mass of keratinized squamous epithelium that occurs in the middle ear or mastoid process occurring most frequently in teenagers. This ear-related metaplasia is not associated with cholesterol or gallbladder problems, as the name suggests. There are two types of cholesteatoma. The congenital type is less common and occurs medial to the tympanic membrane. The acquired type is more common and grows from the tympanic membrane. Conductive hearing impairment prevails, with imbalance and facial weakness being the most common associated symptoms. Examination may reveal inflammation, retrotympanic waxy appearing polyps or white-pasty discharge from the tympanic membrane. As such, this can easily be confused with chronic, suppurative otitis media. Microscopic excision surgery is required to prevent complications and to maintain or improve hearing.

Acoustic neuromas (A) present with sensorineural, not conductive, hearing impairment. Furthermore, these masses occur in the inner ear and temporal bone on the vestibular nerve and would not likely be viewable during an otoscopic examination. Otitis media (C) presents with otalgia, hearing loss, fever and tympanic membrane abnormalities like erythema, bulging, or cloudiness. Although retrotympanic masses can result from chronic suppurative middle ear infections, current infection is unlikely in the above patient. Squamous cell carcinoma (D) is an epithelial cell malignancy that typically occurs on the external, not middle, ear due to prolonged sun exposure. It has an ulcerated, erythematous appearance with or without bleeding.

The patient’s Centor Score is 1 as the patient has tonsillar exudates.

Centor criteria are as follows (each 1 point, for a total of 4 points): Temp >100.4F (38.0C); Absence of cough; Anterior cervical lymphadenopathy; Tonsillar exudates.

The modified Centor criteria factor in age: Age <15 years adds one point; Age >44 years subtracts one point.

0-1 points: no antibiotic or throat culture needed (risk of strep infection <10%)
2-3 points: obtain throat culture and treat if culture positive (risk of strep infection 15% for 2 points, 32% for 3 points)
4-5 points: empirically administer antibiotics (risk of strep infection 56%).

In adults, presence of all 4 original criteria = 40-60% positive predictive value, while absence of all 4 original criteria = 80% negative predictive value.

This patient presents with signs and symptoms concerning for a deep space infection of the neck and should have fiberoptic nasopharyngoscopy performed by a trained clinician. Deep space infections of the lower face and neck include peritnosillar abscess, Ludwig’s angina, retropharyngeal and parapharyngeal abscess. Patients with these disorders can decompensate rapidly and thus, rapid diagnosis and appropriate management is vital. Patients will often present with fever and sore throat and will be ill-appearing. Because these abscesses can compromise the airway, patients may exhibit signs of respiratory compromise including stridor and tachypnea. Trismus may be present if the infection irritates the TMJ and muscles of mastication. Airway distortion is common and intubation should not be taken lightly. The safest approach is typically awake intubation with fiberoptics. Fiberoptic nasopharyngoscopy can be beneficial for diagnosis, visualization of the airway anatomy and for intubation.

This patient is suffering from dry socket, also known as acute alveolar osteitis. Patients undergo dental extraction and after the procedure a hemostatic blood clot forms in the socket. Pain is common for 24 hours post-procedure and then improves. When the healing blood clot is lost from the socket, the patient develops acute severe pain. Most commonly, it occurs 3-4 days after the extraction and is associated with a foul odor. Pain is related to inflammation and a localized infection of the bone. Treatment includes packing the open socket with iodoform gauze. The gauze is saturated with either a medicated dental paste or eugenol (oil of cloves). Patients will require analgesia and may benefit from a nerve block.

This patient has obstructive sialoadenitis, which occurs from outflow obstruction by a stone or calculus in the salivary gland or duct. The submandibular location is most commonly involved because it is has more viscous secretions and runs an uphill course. Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone. Palpable stones may also be “milked” from the duct, if they are distal enough, by gentle stroking in a posterior to anterior direction.

Antihistamines (A) can worsen this condition by decreasing saliva production and are contraindicated. If the sialoadenitis does not resolve with conservative therapy, dilation and incision (B) of the salivary duct is required to remove the stone. Oral antibiotics (C) are not required in simple obstructive sialoadenitis. However, when suppurative sialoadenitis is present, oral antibiotics with staphylococcal coverage are recommended.

This patient is exhibiting signs and symptoms of a peritonsillar abscess (PTA). These abscesses are typically polymicrobial in etiology. Signs and symptoms of a PTA include fever, trismus, hot potato or muffled voice, and contralateral uvular deviation. Management of a PTA is by needle aspiration or incision and drainage, and antibiotics. In order to avoid the internal carotid artery, which sits behind the peritonsillar fossa, a needle sheath should be used to control puncture depth. Aspiration should be undertaken in the soft palate at the point of maximal abscess fluctuance. Medial and superior aspiration are safer from the standpoint of avoiding injury to the carotid artery. Penicillin VK, amoxicillin and clavulanic acid, or clindamycin may be used for antibiotics. Complications of a PTA include airway obstruction, aspiration, deep space or intracranial extension, or inadvertent carotid artery injury during drainage.

The internal jugular vein (B) lies lateral to the area posterior to the peritonsillar abscess. The peritonsillar abscess typically lies superior to the tonsillar pillar (C). The vagus nerve (D) lies significantly more posterior to the peritonsillar abscess than would be reached by the needle or scalpel in draining the abscess.

Avulsed permanent teeth are true dental emergencies. The majority of patients with an avulsed tooth will lose the tooth, so the expectations of patients should be managed accordingly. Time is an important consideration with dental avulsion. Periodontal ligament cells generally die after 60 minutes outside the oral cavity if not replanted or placed in the proper transport media. The ideal transport media is Hank’s solution, but this is not usually available in most homes. Therefore, milk is an alternative and has a compatible osmolality to tooth root cells. However, like normal saline, it lacks the necessary metabolites and glucose to maintain normal cell metabolism of the tooth root cells. The cells on the avulsed periodontal ligament in milk do not die immediately, and is the best alternative to Hank’s solution. Patients should be reminded to avoid touching the periodontal ligament and hold the tooth by the crown. In the ED, temporary replantation should be performed. The tooth should be gently rinsed (not wiped) with care not to traumatize the periodontal ligament cells. The dental socket should be carefully rinsed and suctioned to remove any debris or clot. The tooth can be replanted gently into the socket and then splinted with periodontal dressing material. Dental follow-up should be arranged for the following day.

Hydrogen peroxide (A) is not an appropriate transport solution because it will damage the periodontal ligament cells. Normal saline (C) has a fairly compatible osmolality and will not cause cellular swelling, but it lacks the metabolites and glucose necessary for maintenance of normal cell metabolism. The different pH and osmolality of water (D) has been shown to damage the periodontal root cells.

The coin is in the esophagus and will need to be removed endoscopically. Flat objects (coins) will be oriented in the coronal plane if it is located in the esophagus. An AP or PA radiograph will reveal the flat surface of the coin (as seen in the above radiograph). If it is in the trachea, the coin will be oriented in the sagittal plane (reflecting the angle of the coin required to pass through the vocal cords). The AP or PA radiograph will reveal the coin on edge. The esophageal epithelium can rapidly necrose and perforate with a lodged foreign body; therefore, endoscopy is necessary to remove a foreign body. The patient also is noted to be drooling, which is indicative of partial or complete obstruction.

The patient exhibits signs (drooling) of partial or complete obstruction, thus, intervention rather than observation is necessary. Most foreign bodies tend to lodge at sites where esophageal narrowing occurs. This occurs at the level of the cricopharyngeus muscle (C6) in kids < 4 years old. Once lodged, it is uncommon for the foreign body to pass. Lodged esophageal foreign bodies can cause esophageal necrosis and lead to perforation. Objects lodged in the esophagus that are causing obstruction (A) should be removed emergently. Tracheal foreign bodies (C and D) are oriented in the sagittal plane and appear round on the lateral view, not the AP view, as seen in the above radiograph. All tracheal foreign bodies need emergent removal in the operating room under anesthesia by laryngoscopy or bronchoscopy. Most patients will also exhibit some form of respiratory distress with a tracheal foreign body.

This patient is suffering from a retropharyngeal abscess and will need advanced imaging (CT scan of the neck with IV contrast) to further delineate the extent of the disorder along with emergent ENT consultation for possible operative intervention. Historically, this was a disease of children under 6 years of age but adults are increasingly affected. A number of infectious processes including nasopharyngitis, otitis media, peritonsillar abscess, dental infections as well as iatrogenic procedures including endoscopy and dental instrumentation have been associated with retropharyngeal abscess formation. The infection is most commonly polymicrobial with both aerobes and anaerobes requiring broad antibiotic coverage. Patients typically present with sore throat, odynophagia, dysphagia, drooling, muffled voice, neck stiffness, fever and trismus. In severe cases, the patient may hold the neck in extension in order to increase airway diameter by distracting the posterior pharynx from the airway. CT scan and MRI are diagnostic but in unstable patients, lateral neck X-ray can demonstrate retropharyngeal swelling supporting the diagnosis. Additionally, if the patient is unable to lie flat for advanced imaging, direct visualization with an upper airway scope can be diagnostic.

Oral antibiotics (C) alone are insufficient for treatment of retropharyngeal abscess in the majority of cases. In addition, the patient should not be discharged home as she is at risk to develop a compromised airway. Ibuprofen, dexamethasone, and a Rapid strep test (B) is the standard treatment for simple pharyngitis. However, this patient has a deep space infection and requires imaging, intravenous antibiotics, ENT consultation and possible surgery. In this patient, there is no swelling of the tonsils to suggest a peritonsillar abscess (D) as the cause of the patient’s symptoms.

A. This patient has a dental fracture with exposed pulp. This is a dental emergency requiring dental follow-up within the next 24 hours. The most superficial dental fractures involve only the enamel on the surface and treatment is mostly cosmetic and aimed at dulling any sharp edges. Fractures that expose dentin will have an ivory-yellow appearance. In younger patients, there is less dentin relative to the pulp and treatment is aimed at protecting any pulp contamination with placement of a calcium-hydroxide dressing. Younger patients need more urgent follow-up with a dentist. The most significant dental fractures involve the pulp as in this clinical scenario. The tooth should be gently wiped clean with gauze and inspected for a drop of blood or pink blush which represents pulp exposures. The area is usually exquisitely painful. Timely follow-up (within 24 hours) is required for evaluation and possible root canal and extraction of the pulp. If dental follow-up will be delayed, the tooth should be covered with moist cotton and sealed with dry foil or a temporary commercial sealant. In order to clean the tooth, a clean gauze should be used to wipe off the surface, not irrigation of the tooth (B) as the patient will be extremely sensitive to that and all efforts should be maintained to avoid pulp contamination. Hank’s solution (C) is a physiologic solution in which an avulsed tooth may be placed while waiting for reimplantation into the socket. There is no role in a partial tooth fracture. Viscous lidocaine (D) is not an appropriate analgesic for a dental fracture. Oral analgesics or dental block should be provided for pain control.

In ANY case of chemical exposure to the eye the first step is irrigation of the eye, and while pH should ideally be measured immediately it should NOT delay irrigation. Note that tetracaine is an acidic substance and if administered prior to pH measurement it may give a false reading.  The pH of this patient’s eye is 8, and the goal pH of the eye should be 7.0-7.4  and irrigation should continue until that is achieved to prevent further liquefactive necrosis in this case (remember that acidic injury causes coagulative necrosis and basic injury causes liquefactive necrosis).  Emergent Ophtho consult is indicated. Once the goal pH is met, the eye should subsequently be stained with fluorescein and examined for any abrasion or ulceration.

This image depicts Seidel’s sign (fluorescein moves away as contents (which appear yellow-green) leak out at site of globe rupture). When a globe rupture is suspected you should avoid any manipulation of the eye (tonometry is contraindicated!). While awaiting emergent ophthalmology consultation for operative repair, a CT orbit should be performed to rule out posterior ocular injury as well as identification of the foreign body. A tetanus vaccine should be documented as up-to-date, as well as prophylactic systemic antibiotics, any pain should be adequately controlled, and anti-emetics provided (to prevent further extrusion of ocular contents due to increased intraocular pressure when vomiting).

Patient is presenting with a Grade I hyphema. Treatment recommendations for a mild hyphema are bed rest, head of bed elevation to encourage layering out of red blood cells and clot formation. Ophtho follow up and discussion of risk of rebleeding from clot contraction are also indicated.  Only severe cases of Grade IV aka “eight-ball” hyphema require surgical drainage/admission.  An exception to this management plan is sickle cell patients, in which a hyphemia is emergent and requires ophtho consultation immediately.  Additionally, anti-coagulation medications may cause or increase risk of developing a hyphema.

Diffuse superficial punctate keratitis (SPK) is usually an acute process arising from contact lens complications, UV exposure from welding or snow blindness, chemical exposure, topical eye medication toxicity, or in extreme dry eye cases. Symptoms include red eye, pain, photophobia, foreign body sensation, +/- mildly decreased visual acuity. Defining features of SPK on fluorescein stain include: pinpoint corneal epithelial defects that enhance. Classically, pain is relieved by the instillation of anesthetic drops, suggesting corneal epithelial involvement.

Non-contact lens wearers with a small amount of SPK should receive artificial tears +/- lubricating ointment. Severe amounts of SPK should also receive topical antibiotics such as erythromycin ointment for 3-5 days. Ophthalmology followup is usually on a non-emergent basis.

Contact lens wearers with a small amount of SPK should discontinue contact lens use until the condition resolves, with artificial tears +/- lubricating ointment. Severe amounts of SPK should also receive topical antibiotics such as fluoroquinolone or tobramycin. Urgent ophthalmology followup should be given.

A hordeolum or stye is an abscess of the eyelid. It presents with pain, erythema, and swelling. Most resolve without intervention. Warm compresses for 15 minutes four times a day may help facilitate drainage. If the hordeolum does not improve in one to two weeks, the patient should be referred to an ophthalmologist for potential incision and drainage or antibiotics.

mnemonic: the Hordeolum is HOT and the Chalazion is COLD, but regardless of what it is warm compress you’ll hold

The hordeolum is an infectious process so will be inflammed and painful, while the chalazion is a painless “cold” cyst, regardless first line treatment is conservative

Retinal detachment’s should be suspected in patient’s with monocular vision loss symptoms. They can be seen in older diabetic patients, however should be suspected in younger patients with trauma such as motor vehicle crashes, skydiving, bungee jumping, and other activities with sudden deceleration forces are risk factors. Patients with myopia (such as this patient) are at higher risk of traumatic retinal detachment. Diagnosis can be made with indirect ophthalmoscopy or ultrasound. Ultrasound will show a discrete hyperechoic retinal line projecting out from the posterior globe.  Patients usually present with painless vision changes, including flashes of light, floaters, or the classic “curtain-like” loss of vision. Retinal detachment is an ophthalmologic emergency and early intervention can prevent worsening of the detachment.

Involvement of the macula is important to determine. If the retinal detachment involves the macula (“mac on”) it is LESS emergent than if the macula is not involved (“mac off”), this is because emergent surgical correction can salvage the macula in a “mac off” situation.

Retinal detachment is usually a thicker line which will not cross over the optic nerve as the retina is an extension of the nerve. This is in comparison to posterior vitreal hemorrhage which appears as a whispy thin line which can cross over the optic nerve. See the video link below.

http://5minsono.com/rdvd/

This patient presents with dacryocystitis and should be treated with oral anti-staphylococcal antibiotics. Dacryocystitis is an acute infection of the lacrimal sac secondary to lacrimal duct obstruction. Given the obstruction of the lacrimal duct, topical abx treatment of the eye alone will not provide penetration into the infected area. It is typically caused by Staphylococcus aureus. Symptoms include swelling, redness, pain and tenderness to palpation over the lacrimal sac. Diagnosis can be aided with a fluorescein stain, aka fluorescein disappearance test, which sill either show lack of clearance of fluorescein dye to the eye over 5 minutes or fluorescein spilling out as tears (normal eye will clear fluorescein in <5 minutes). In addition to oral antibiotics, patients should be treated with warm compresses and gentle massage of the area. Complications of improperly treated dacryocystitis include peri-orbital and orbital cellulitis.

This patient’s fluorescein exam is consistent with a corneal abrasion. It is caused by direct mechanical damage, leading to a partial-thickness corneal injury. Athletes, contact lens wearers, welders, and glass workers may present more often with these injuries. Diagnosis is confirmed when fluorescein dye highlights the usually linear or punctate abrasions. Multiple vertical corneal abrasions may indicate a retained foreign body beneath the eyelid. Corneal abrasion fluorescein exam findings are not to be confused with open globe injuries (streaking of the dye from the site of injury), corneal ulcers (circular patches of dye uptake with ragged, “heaped up” edges), and herpes simplex keratitis (dendritic pattern uptake). Patients commonly present with eye pain and tearing with a usually known mechanism of injury. The mainstay of treatment includes pain control, infection prophylaxis, updating tetanus as needed and preventative care to avoid abrasions in the future. For non-contact wearers prescribe erythromycin ointment, as this does not cover pseudomonal infections, contact lens wearers should be prescribed  ciprofloxacin or tobramycin ophthalmic drops

A lateral canthotomy should be performed in this woman who presents with classic symptoms for a traumatic injury causing retrobulbar hematoma and resultant orbital compartment syndrome. She displays the triad of symptoms including loss of vision, ophthalmoplegia, and proptosis. A retrobulbar hemorrhage from a ruptured infraorbital or ethmoidal artery with intact orbital walls may lead to orbital compartment syndrome. Loss of vision is irreversible 60–100 minutes after the onset of ischemia and so lateral canthotomy and inferior cantholysis should be performed in order to decompress the orbit and preserve vision. Intraocular pressure-lowering agents such as intravenous carbonic anhydrase inhibitors, topical beta-blockers, alpha agonists, and intravenous mannitol are temporizing measures.

This patient has traumatic endopthalmitis. Suspicion should be high in any patient with recent trauma or intraocular surgery and signs/symptoms of infection or with hypopyon (purulent/white layering of fluid in anterior chamber). Manipulation of the eye should be avoided due to concern for globe rupture in this patient (e.g. ocular US/tonometry). A stat CT orbit is indicated to examine for foreign body. Systemic antibiotics are indicated in traumatic endopthalmitis, treatment should be broad-spectrum and common courses include vanc/ceftazidime. While at DRH vanc/cefepime is commonly used to treat various infections, BE AWARE that cefepime has relatively poor penetration into the vitrea and is not recommended. Common pathogens include staph/strep and oddly enough bacillus cereus.  Topical antibiotics alone are insufficient. It is essential to consult ophthalmology as definitive management is generally surgical: vitrectomy and intra-vitreal abx injection.