Podcast Ep 24: Preeclampsia, Scombroid, Influenza, HACE, & More

Shoot for the moon and if you miss you will be among the stars.

-Les Brown

Welcome back to Episode 24! We are coming to you live from Orlando at SAEM this week. Ok, it is not exactly live, but we are launching this episode from Orlando. Although the venue has changed, we have the same high-quality review for you this week. This week we begin with a renal rapid review and then get into the new material, starting with some OB and virology, and ending with the more obscure, but still important, altitude-related emergencies. Hope you enjoy!

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• When considering children with glomerulonephritis, in a child with mild to moderate edema, a normal blood pressure, and no respiratory symptoms, discharge home with corticosteroids may be appropriate.
• Winter’s formula, pCO2 = 1.5HCO₃^– + 8 ± 2, is used to determine if there is appropriate respiratory compensation in a metabolic acidosis.  
• The causes of a non-anion gap metabolic acidosis can be remembered with the mnemonic HARDASS: Hyperalimentation, Addison’s disease, RTA, Diarrhea, Acetazolamide, Spironolactone, and Saline infusion.

Now onto this week’s podcast

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Question 1

A 17-year-old G1P0 woman at 25 weeks gestation presents with intermittent blurred vision. On presentation, she is asymptomatic. Vital signs are HR 84, BP 175/113, and oxygen saturation 97%. Physical examination reveals 2+ pitting edema on both lower extremities and urinalysis has 3+ protein on dip. Which of the following is most likely indicated?

A. Admit for further obstetrics evaluation

B. Antiepileptic medications

C. Arrange follow-up with the patient’s obstetrician

D. Emergency cesarean section

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Question 2

Which of the following fish poisonings is associated with a peppery taste?

A. Aeromonas

B. Ciguatera

C. Scombroid

D. Vibrio

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Question 3

What is the most common cause of viral pneumonia in adults?

A. Influenza virus

B. Metapneumovirus

C. Parainfluenza virus

D. Respiratory syncytial virus

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Question 4

Which of the following is the most common visceral artery aneurysm?

A. Hepatic artery aneurysm

B. Inferior mesenteric artery aneurysm

C. Splenic artery aneurysm

D. Superior mesenteric artery aneurysm

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Question 5

A 14-year-old girl is brought to your mountaineering base camp at 11,000 feet for evaluation of strange behavior while attempting to summit a nearby peak with her school group. What is the most sensitive clinical sign in diagnosing high-altitude cerebral edema?

A. Cerebellar ataxia

B. Cranial nerve VI palsy

C. Ptosis

D. Seizure

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Question 6

A 33-year-old man presents to the ED with right eye pain, tearing, and “difficulty seeing” out of the right eye. His visual acuity is 20/30 on the left and 20/200 on the right. On physical exam, you notice a subconjunctival hemorrhage and teardrop-shaped pupil. Which of the following physical exam findings is consistent with the suspected diagnosis?

A. Cells and flare in the anterior chamber on slit lamp exam

B. Gross retinal hemorrhage on dilated funduscopic exam

C. Intraocular pressure measurement of 52 mm Hg

D. Positive Seidel test on fluorescein stain exam

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Teaching Video

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• Preeclampsia is defined as gestational hypertension after 20 weeks, with a blood pressure of 140/90 or higher and either proteinuria or signs of end-organ damage.
• The definitive and curative therapy for preeclampsia is delivery of the baby. Magnesium may be given for seizure prophylaxis.
• Both hydralazine and labetalol can be safely used in pregnancy to control blood pressure.
• HELLP syndrome is a severe variant or complication of preeclampsia. It is characterized by hemolysis, elevated liver enzymes, and low platelets.
• Scombroid poisoning may cause a metallic, bitter, or even peppery taste.
• Scombroid poisoning results from the breakdown of histidine into histamine resulting in facial flushing, diarrhea, severe throbbing headache, palpitations, and abdominal cramps.
• Ciguatera poisoning leads to nausea, vomiting, diarrhea, myalgias, tingling and numbness, abdominal pain, and vertigo along with the classic association of hot and cold sensation reversal. In severe cases, hypotension, bradycardia, and coma may result.
• The most common viral cause of pneumonia in adults is influenza.
• Influenza is also the most common viral cause of rhabdomyolysis.
• Splenic artery aneurysms are the most common visceral artery aneurysm.
• Splenic artery aneurysms are managed with embolization in asymptomatic patients and operatively in those who are symptomatic.
• The most sensitive clinical sign for diagnosis of high altitude cerebral edema (HACE) is cerebellar ataxia. Other signs include encephalopathy, severe lassitude, and a progressive decline of mental function and consciousness.
• HACE is managed definitively with descent. Steroids, supplemental oxygen, and hyperbarics may also be used.
• Globe rupture can be identified by a positive Seidel test on fluorescein stain exam. CT can also help in making the diagnosis.
• Globe rupture should be managed by covering the eye with a shield, elevating the head of the bed, updating the tetanus vaccine, and starting antibiotics. Operative emergent repair is a must.

So that wraps up Episode 24. We will be in Orlando for a few more days, so please stop us and let us know what you think. We are always looking for ways to make Roshcast even better and are open to any ideas and suggestions. As always, don’t forget to follow us on Twitter @Roshcast for updates, high-yield images, and pearls in 140 characters or less.

Until next time,
Jeff and Nachi