Questions, Board Review

Board Review Questions: January 2024

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1. When a Sengstaken-Blakemore tube is used in the management of variceal bleeding, which measure is taken to avoid esophageal perforation?

A. Decreasing esophageal balloon pressure by 5 mm Hg every 3 hours
B. Inflating the esophageal balloon before the gastric balloon
C. Inflating the esophageal balloon to a pressure of 100 mm Hg
D. Nasogastric suctioning of stomach contents before tube placement

The correct answer is A, Decreasing esophageal balloon pressure by 5 mm Hg every 3 hours.

Why is this the correct answer?
Sengstaken-Blakemore tube insertion can be a lifesaving temporizing procedure for variceal bleeding, but it is performed infrequently because of its associated complications and the development of endoscopic therapies. One significant complication is esophageal or gastric rupture. When bleeding is controlled, the esophageal balloon pressure should be reduced by 5 mm Hg every 3 hours down to a pressure of 25 mm Hg to avoid pressure necrosis. The correct placement of the Sengstaken-Blakemore tube is accomplished with the large balloon advanced completely into the stomach. Appropriate positioning can be confirmed with imaging or by auscultating over the stomach while insufflating air into the gastric port.

The gastric balloon is initially inflated with about 250 mL of air so that it abuts securely against the gastroesophageal junction. Once fixed, the esophageal balloon is inflated if bleeding persists. Notably, the esophageal balloon is inflated to a pressure of no more than 50 mm Hg to control esophageal variceal bleeding. Intragastric balloon pressure should be reassessed frequently after placement; increasing pressure may signify esophageal placement or migration. Aspiration and airway compromise are concerns during Sengstaken-Blakemore tube placement, so elevation of the head of the bed and endotracheal intubation should both be strongly considered.

Why are the other choices wrong?
The gastric balloon should be inflated first, not the esophageal balloon. Ensure that it is clearly in the stomach before full inflation. This intervention controls gastric varices. If bleeding stops after gastric balloon inflation, the esophageal balloon does not have to be inflated.

A pressure of 100 mm Hg is too high. The esophageal balloon should be inflated to a pressure of no more than 50 mm Hg to control esophageal variceal bleeding.

Oral or nasogastric suctioning is necessary after the placement of a Sengstaken-Blakemore tube (not before) to decrease the risk of aspiration because secretions collect above the obstructing tube. Nasogastric tube placement before or after Sengstaken-Blakemore tube placement does not affect the risk of rupture.

REFERENCES

DeGeorge LM, Nable JV. Gastrointestinal bleeding. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 10th ed. Elsevier; 2023:240-245.

Ziebell CM, Kitlowski AD, Welch J, Friesen P. Upper gastrointestinal bleeding. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:495-498.

EMCrit RACC video on Blakemore tube placement

https://emcrit.org/emcrit/blakemore-tube-placement/

UpToDate article on achieving hemostasis in patients with acute variceal hemorrhage, available in full with a subscription

https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage


2. A 7-year-old boy presents for evaluation of a rash that developed after he was sick with a fever and sore throat. His mother first noticed the rash on his face and became worried when it spread to his neck. The physical examination reveals a red rash that feels like sandpaper on the child's face, neck, and upper trunk. Which pharmacotherapy should be administered?

A. Diphenhydramine
B. Doxycycline
C. Penicillin
D. Sulfamethoxazole-trimethoprim

The correct answer is C, Penicillin.

Why is this the correct answer?
Scarlet fever is an exotoxin-mediated illness caused by infection with Streptococcus. It occurs primarily in children and is treated with penicillin. The rash is distinctive — red and rough with a sandpaper-like texture because of the multitude of pinhead-sized lesions. Scarlet fever's rash begins on the face and upper trunk and spreads rapidly within 12 to 48 hours of the onset of fever, chills, malaise, and sore throat. Other classic findings of scarlet fever are a red, beefy tongue (strawberry tongue), erythematous lesions or petechiae on the palate (Forchheimer spots), capillary fragility causing petechiae in the flexural surfaces (Pastia lines), and facial flushing with circumoral pallor. The rash typically resolves in 1 week and is followed by desquamation, especially of the palms and soles.

Early complications of scarlet fever include infection of lymph nodes, tonsils, middle ear, and respiratory tract. Late complications include rheumatic fever and acute glomerulonephritis. Treatment is 10 days of oral penicillin VK 50 mg/kg per day (40,000-80,000 units) in four divided doses in children or 250 mg four times a day. Intramuscular benzathine penicillin is another option; dosing is 300,000 units in patients weighing less than 30 pounds (<13.6 kg), 600,000 units in patients weighing 31 to 60 pounds (14.1-27.2 kg), 900,000 units in patients weighing 61 to 90 pounds (27.7-40.8 kg), and 1.2 million units in patients weighing more than 90 pounds (>40.8 kg). In patients with a penicillin allergy, clindamycin or cephalexin can be used.

Why are the other choices wrong?
Diphenhydramine is an antihistamine, and it would work well for a rash caused by an allergic reaction. However, the rash that develops with scarlet fever is exotoxin mediated, not a hypersensitivity reaction; its source, Streptococcus, is treated with antibiotics.

The tetracycline family of medications is used to treat several conditions associated with rash, including Rocky Mountain spotted fever and Lyme disease. There is a high resistance of Streptococcus to tetracycline, so doxycycline is a poor choice for treatment of scarlet fever. Although many physicians have been reluctant to use tetracyclines in children because of concern for dental staining, this outcome has been shown to be less serious than previously thought.

Sulfamethoxazole-trimethoprim is a sulfonamide and is not recommended for treating pharyngitis. There is a high level of resistance to sulfonamides for group A beta-hemolytic Streptococcus. Sulfonamides do not seem to eradicate the bacteria in the posterior pharynx even when the culture indicates there may be appropriate sensitivity. 

REFERENCES

McFarlin AK, LeGros TL, Murphy-Lavoie H. Approach to the pediatric patient with a rash. In: Adams JG, Barton ED, Collings JC, DeBlieux PMC, Gisondi MA, Nadel ES, eds. Emergency Medicine Clinical Essentials. 2nd ed. Elsevier Saunders; 2013:149-158.

UpToDate article on complications of streptococcal tonsillopharyngitis, available in full with a subscription

https://www.uptodate.com/contents/complications-of-streptococcal-tonsillopharyngitis

Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov 15;55(10):1279-1282.

Nguyen M, Dunn AL. Rashes in infants and children. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:925-944.


3. A 23-year-old woman presents with wrist, knee, and ankle pain of 4 days' duration. The pain started in her left wrist and ankle, but the pain in her right knee has progressively worsened over the past 24 hours. Small, diffuse papules are noted, including on her palms. She denies trauma. On examination, the right knee is diffusely hot, red, and swollen; no deformities are noted, and other joints appear normal. Arthrocentesis is performed, and the synovial fluid is sent for culture, Gram stain, crystals, and cell count. What additional testing is needed to confirm the diagnosis?

A. Cultures of joint fluid from surgical irrigation
B. Cultures of the pharynx and vagina
C. Lyme titers
D. Serum uric acid level

The correct answer is B, Cultures of the pharynx and vagina.

Why is this the correct answer?
Gonococcal septic arthritis is the most common form of septic arthritis in adolescents and young adults, and it has a greater female:male predominance. Because cultures of synovial fluid are positive less than 50% of the time, the physician should obtain specimens for culture from other parts of the body where Neisseria gonorrhoeae may be found (eg, the posterior pharynx, urethra or cervix, or rectum). This patient has the typical symptoms of gonococcal septic arthritis: the classic triad of a migratory arthritis in multiple joints, papular or pustular rash, and inflammation of the tendon sheaths.

Confirming the diagnosis is important because the treatment of gonococcal septic arthritis is different from that for the nongonococcal type. Gonococcal septic arthritis can be treated with intravenous antibiotics alone (thus avoiding surgical joint irrigation) because it rarely results in the joint destruction that is more typical of nongonococcal septic arthritis. The most effective antibiotic for treating gonococcal septic arthritis is a third-generation cephalosporin such as ceftriaxone, and this approach should continue until all culture results are in. When the diagnosis is unknown initially, many physicians add vancomycin. Vesiculopustular lesions should be looked for on a skin examination, including the classic rash on the palms and soles. This rash is seen in nearly half of patients with this disease, so it can help make the diagnosis. The rash can range from hemorrhagic papules to pustules.

Why are the other choices wrong?
Taking a patient to surgery for joint irrigation is usually required in the treatment of nongonococcal septic arthritis, which is highly associated with joint destruction. Joint aspiration is essential to diagnosing septic arthritis, but its sensitivity is poor. Septic arthritis is usually considered with the accepted cutoff of 50,000 cells/mm3. Measuring ESR and C-reactive protein can also help make the diagnosis, but these are nonspecific indicators. Nongonococcal septic arthritis is usually monoarticular; polyarticular involvement is present in less than 20% of adult cases.

Lyme arthritis starts with a migratory polyarthritis but typically evolves into a monoarticular process. In contrast to patients with gonococcal arthritis, those with Lyme arthritis typically have brief, recurrent attacks from weeks to months after infection. These attacks cause joint swelling and pain, which progress to chronic arthritis. These patients live in or have traveled to areas known to be associated with Lyme disease, but they may or may not have a history of tick bite or rash.

Measuring a patient's serum uric acid level would be reasonable if the suspected diagnosis were gout. However, up to 30% of patients with gout have a normal uric acid level during an acute attack, so a serum uric acid level is not particularly helpful in diagnosing gout. Moreover, most patients with gout are older than 40 years and present with symptoms in the great toe or the knee. Gout is usually a monoarthritis and is often preceded by trauma, surgery, a change in medication, or illness.

REFERENCES

Raukar NP, Zink BJ. Bone and joint infections. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 2. 10th ed. Elsevier; 2023:1711-1728.

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.


4. Which patient characteristic is considered to be the greatest risk factor for suicide completion?

A. Age >75 years
B. Female sex
C. Married
D. Urban living

The correct answer is A, Age >75 years.

Why is this the correct answer?
According to the National Center for Health Statistics, the suicide rate in the United States rose 24% over a 15-year period ending in 2014. Although there were sharp increases among women aged 45 to 64 years and girls aged 10 to 14 years, the highest suicide rate is still in men older than 75 years. Suicide risk must be assessed on an individual basis, but various risk factors have been identified. The SAD PERSONS scale, which was originally published in 1983 and has since been modified and adapted, is a helpful tool to assess suicide risk according to patient characteristics such as sex, age, depression, previous attempt, social factors, and more.

Patients with depression and suicidal ideation frequently present to the emergency department. When assessing patients with depression, one of the most important tasks is to assess for suicidality. Although women attempt suicide more frequently, men are four times more likely to complete suicide. Another key factor on the scale is sickness — particularly chronic, debilitating, or severe illness. Other notable risk factors include concomitant substance abuse, lack of a spouse, previous suicide attempts, access to a firearm, and a history of childhood abuse. Adults with a history of childhood maltreatment have been found to be 25 times more likely to attempt suicide than those without such a history.

Why are the other choices wrong?
Sex is a factor on the SAD PERSONS scale and should be considered in the risk assessment of those contemplating suicide. Although the gap has narrowed over the past decade, men are still far more likely to complete suicide than women.

People who are married and who have other forms of social support are less likely to die by suicide. Unmarried and single people have a higher risk of suicide.

The highest rates of suicide in the United States occur in rural environments. Living in an urban environment — especially in a medium or small metropolitan area rather than a large one — carries less risk of suicide.

REFERENCES

Hockberger RS, Rothstein RJ. Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS scale. J Emerg Med. 1988 Mar-Apr;6:99-107.

DeSelm TM. Mood and anxiety disorders. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1946-1952.

Gray C. Assessment of the suicidal patient in the emergency department. In: Zun L, Chepenik LG, Mallory MNS, eds. Behavioral Emergencies for the Emergency Physician. Cambridge University Press; 2013:60-68.

Patterson WM, Dohn HH, Bird J, Patterson GA. Evaluation of suicidal patients: The SAD PERSONS Scale. Psychosomatics. 1983 Apr;24(4):343-345.

UpToDate article on suicidal ideation and behavior in adults, available in full with a subscription

https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults


5. A 24-year-old man presents with a red and painful eye. An examination reveals what appears to be a foreign body in the cornea. What is the best next step in management?

A. Attempt to remove the object with a moistened cotton applicator
B. Discharge the patient home with instructions to use erythromycin ointment
C. Patch the eye closed, and arrange ophthalmology follow-up in 48 hours
D. Use a burr drill to remove the rust ring

The correct answer is A, Attempt to remove the object with a moistened cotton applicator.

Why is this the correct answer?
The next best step would be to attempt to remove the object with a moistened cotton applicator. Corneal foreign bodies are most commonly pieces of wood, plastic, or metal, and they are typically superficial and benign. After the cornea has been appropriately anesthetized, a slit lamp should be used to assess the depth and size of the foreign body. Irrigation of the eye may remove very superficial foreign bodies. If irrigation is unsuccessful, a moistened cotton applicator can be used to dislodge the object. A burr drill or an 18-gauge needle with the bevel up can also be used if other methods are unsuccessful. If a rust ring remains after the foreign body has been removed, a rotating burr can be used to remove superficial rust, but care must be taken to avoid penetrating the cornea. The burr drill should not be used if the rust ring is in the visual axis because it can lead to a vision-impairing scar.

A topical antibiotic, such as erythromycin, should be prescribed when the patient is discharged. This treatment is similar to that for a corneal abrasion, but the foreign material should be removed first.

It is inappropriate to discharge the patient with ophthalmology follow-up without first attempting to remove the foreign object or at least discussing the plan of care with an ophthalmologist. If attempts to remove the foreign object are unsuccessful, follow-up with an ophthalmologist within 24 hours is warranted. Patching the eyelid closed has been used in the treatment of corneal abrasions, but recent evidence suggests no benefit in healing times and a possible increase in infection rates. Thus, it is no longer routinely recommended.

Although it is necessary to remove the rust ring, the first step should be to remove the foreign object. Superficial rust can then be removed with the burr drill, or the ophthalmologist can remove it at the follow-up appointment. Rust often reaccumulates, so it is unnecessary to completely remove the rust if the patient has a follow-up appointment the next day.

REFERENCES

Knoop KJ, Dennis WR. Ophthalmologic procedures. In: Roberts JR, Custalow CB, Thomsen TW, et al, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019:1295-1337.

Walker RA, Adhikari S. Eye emergencies. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020:1523-1560.

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