Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


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teeth results in
movement of the midface and zygoma together. The LeFort III fracture has the highest incidence of CSF
rhinorrhea. Of note, these fractures rarely occur in their pure form and usually present in combination. Plain \ufb01lms
may demonstrate these fractures but CT imaging is generally needed to delineate the extent and number of
fractures present. Treatment includes airway management, prophylactic antibiotics, and surgical evaluation. Tripod
fractures generally result from a blow to the cheek and involve fractures at the zygomatic arch, zygomaticofrontal
suture, and infraorbital rim.
112 Emergency Medicine Q & A: Pearls of Wisdom ...
36. Regarding acute necrotizing ulcerative gingivitis (ANUG):
a. Herpes virus is the most commonly implicated pathogen.
b. Metallic taste and foul breath are common presenting complaints.
c. Systemic symptoms, such as fever and malaise, are uncommon.
d. Systemic antibiotics are generally not helpful.
e. Dental follow-up is recommended on an as-needed basis.
The answer is b. Acute necrotizing ulcerative gingivitis (ANUG or \u201ctrench mouth\u201d) is a periodontal infection
caused by fusobacteria and spirochetes. Patients present complaining of gingival pain, a metallic taste, and foul
breath. Systemic symptoms such as fever, malaise, and regional lymphadenopathy are common. On examination,
the gingiva is swollen and \ufb01ery red. The interdental papillae are ulcerated or \u201cpunched out\u201d and covered with a
grayish pseudomembrane. Treatment includes warm saline irrigation, antibiotics (PCN, erythromycin, or
tetracycline), systemic analgesics, and local topical anesthetics. Antibiotics often provide dramatic relief within 24
hours. Dental follow-up is required because ANUG can be complicated by the destruction of underlying alveolar
bone.
37. A 32-year-old alcoholic man presents with facial pain and swelling. He reports dif\ufb01culty swallowing as well as
trouble opening his mouth. He sits with his lower jaw slightly thrust out and chin extended. His temperature
is 38.9\u25e6C (102\u25e6F). There is marked submandibular swelling bilaterally and the tongue is slightly elevated. A
periapical tooth abscess of the second right lower molar is noted on examination. Your next step is to:
a. Prescribe oral penicillin, PRN analgesics, and discharge home.
b. Administer a tetanus booster and tetanus immune globulin at two separate sites and consider admission to the
ICU for prophylactic neuromuscular blockade.
c. Perform local I&D of the periapical abscess and discharge home.
d. Administer high-dose penicillin and metronidazole IV, obtain immediate ENT consultation, and admit to the
ICU.
e. Administer diphenhydramine and prednisolone IV and observe in the ED for 6 hours.
The answer is d. Ludwig\u2019s angina is a progressive cellulitis of the \ufb02oor of the mouth involving the sublingual,
submandibular, and submaxillary spaces bilaterally. It is a polymicrobial infection of mixed aerobic and anaerobic
bacteria. The most commonly isolated organisms are streptococci, staphylococci, and Bacteroides sp. Signs and
symptoms include fever, drooling, dysphagia, dysphonia, and trismus. The most common physical examination
\ufb01ndings are bilateral submandibular swelling and elevation of the tongue. The swelling is often noted to be
\u201cbrawny\u201d or \u201cwoody\u201d in nature. Since most of these infections are odontogenic in origin, it is not uncommon for
an infected or recently extracted tooth to be present on examination.
38. The usual complaint of a patient with optic neuritis is:
a. Flashing lights and a visual \ufb01eld defect.
b. Sudden, painless, diffuse monocular vision loss.
c. Rapidly progressive loss of central vision.
d. Gradual loss of peripheral vision.
e. None of the above.
... CHAPTER 7 Head, Eye, Ear, Nose, and Throat Emergencies 113
The answer is c. Optic neuritis is an in\ufb02ammatory process of the optic nerve. It is often characterized by loss of
central vision with preservation of peripheral vision. Visual loss ranges from mild to severe and is rapidly progressive
over hours to days. Associated symptoms include painful extraocular movements and red vision desaturation. An
afferent pupillary defect (Marcus-Gunn pupil) is almost universally present. The disc may be normal (retrobulbar
optic neuritis) or swollen and hyperemic (anterior optic neuritis). Of note, approximately 30% of patients
presenting with acute optic neuritis will develop multiple sclerosis within 5 years.
39. After 2 days of URI symptoms, a 3-year-old girl has developed a barking cough and moderate stridor. The
parents state that her condition is worse at night. Physical examination shows a low-grade fever of 38\u25e6C
(100.4\u25e6F), pulse of 140, respirations of 40, and inspiratory stridor at rest. Following two treatments of
racemic epinephrine the child\u2019s stridor has resolved. At this point you should:
a. Provide instructions to use a cool-mist humidi\ufb01er and discharge home.
b. Prescribe ampicillin and discharge home.
c. Administer steroids and discharge home.
d. Administer steroids and observe the patient for at least 3 hours.
e. Obtain a lateral soft tissue x-ray of the neck and emergent ENT consultation.
The answer is d. Croup, most commonly caused by parain\ufb02uenza virus, is usually a benign, self-limited disease
characterized by edema and in\ufb02ammation of the upper airway. It most often occurs in children 6 months to 3 years
of age in the late fall and early winter. The typical history is 2\u20133 days of a URI with a gradually worsening cough,
especially at night. Fever is absent or low grade and the child is nontoxic in appearance. Treatment may include
cool-mist, oxygen, steroids, racemic epinephrine, and Heliox in severe cases. Steroids should be administered to any
child with moderate to severe stridor and any child who receives racemic epinephrine. Racemic epinephrine is
usually reserved for children with resting stridor and respiratory distress that does not respond to supportive
measures. Children who respond to racemic epinephrine should be observed for at least 3 hours prior to \ufb01nal
disposition.
40. The Centor criteria for determining which patient with a sore throat should receive antibiotics:
a. Rarely leads to overtreatment.
b. Are not valid in children.
c. Determine which antibiotic will be most effective.
d. Were developed in an attempt to reduce the occurrence of acute rheumatic fever.
e. Includes both historical and anatomic \ufb01ndings.
The answer is e. Centor criteria (presence of tonsillar exudates, tender anterior cervical adenopathy, fever by
history, and absence of cough) combine both historical features and physical \ufb01ndings to help determine which
patient has streptococcal pharyngitis and therefore may bene\ufb01t from treatment with antibiotic. They are equally
valid in adults and children; some experts recommend adding one point for patients younger than 15 years and
subtracting one point for patients older than 45 years. The criteria do not determine which antibiotic should be
used, only which patient should be treated with antibiotic. Even in patients with all four Centor criteria (high
pretest probability), overtreatment will occur in approximately 50% of cases.
114 Emergency Medicine Q & A: Pearls of Wisdom ...
41. The most sensitive test for determining maxillary sinusitis is:
a. Sinus x-ray.
b. CT scan.
c. Percussive tenderness.
d. Transillumination.
e. Ultrasound.
The answer is b. Radiologic studies do not have a signi\ufb01cant clinical role in the diagnosis of acute rhinosinusitis.
Coronal CT scan of the sinuses is the most sensitive test. Transillumination is probably more useful (and practical)
in the emergency department. None of these methods can determine whether the patient has a bacterial infection
amenable to treatment with antibiotics.
CHAPTER 8
Hematologic and
Oncologic Emergencies
Sachin J. Shah, MD, MBA, FAAEM
1. In children with sickle cell disease presenting with osteomyelitis,