Podcast Ep 15: BNP, Pneumothorax, Angioedema, & More

All our dreams can come true — if we have the courage to pursue them. 

-Walt Disney

Welcome back to episode 15! As promised, we are back to our weekly episodes leading into the ITE. We start this week with a rapid review of some of the infectious disease high-yield points that we have covered in the past few months, and then we dive right into the new material. Stay tuned for some comical outtakes at the end of the podcast for an inside look at the recording of Roshcast. We think you will enjoy it. Let’s get on with the rapid review.

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• The most common cause of a painless, clean-based, sharply defined penile ulcer is a chancre, seen in syphilis.
• The small shallow ulcer of LGV and the red beefy ulcer of granuloma inguinale are painless also.
• Corneal abrasions can be treated with either erythromycin ointment or ciprofloxacin drops. Do not forget to update the tetanus vaccine if indicated.
• Native valve endocarditis is seen most commonly in the mitral valve.
• The most common cause of pneumonia in alcoholics is Streptococcus pneumoniae.

Now onto this week’s podcast

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Question 1

Which of the following is the most common infection associated with erythema multiforme?

A. Borrelia burgdorferi

B. Haemophilus influenzae type b

C. Hepatitis C virus

D. Herpes simplex virus

Teaching image 

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Question 2

Which of the following patients is at highest risk for developing a pneumothorax?

A. A 33-year-old woman with AIDS 

B. A 45-year-old man with COPD who is maintained on inhaled steroids

C. A 56-year-old obese woman with sleep apnea who uses BiPAP at night

D. A 65-year-old man with heart failure and NY Heart Association Class 3

Teaching image 

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Question 3

A 72-year-old man presents with chest heaviness associated with diaphoresis and shortness of breath. His ECG demonstrates complete heart block. Acute blockage of which of the following coronary arteries is most likely to be causing his dysrhythmia?

A. Left anterior descending artery

B. Left circumflex artery

C. Left coronary artery

D. Right coronary artery

Teaching image

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Question 4

Which of the following can decrease levels of brain natriuretic peptide?

A. Elderly age

B. Female sex

C. Kidney failure

D. Obesity

Teaching image

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Question 5

A 55-year-old woman presents to the ED for swelling of her tongue and lips. She recently started a new antihypertensive medication. Which of the following is the direct mediator for her condition

A. Angiotensin 

B. Bradykinin

C. C1-esterase inhibitor

D. Histamine

Teaching image 

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Question 6 

Which of the following signs of acute arterial occlusion requires emergent surgical intervention

A. Pain

B. Pallor

C. Paralysis

D. Poikilothermia

Teaching image

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Question 7

A 3-year-old boy presents with stridor. His mother states that he was eating a grape and suddenly started choking. The patient has normal vital signs except for an increased respiratory rate. Physical examination reveals an anxious child who is able to speak, but has stridor. Which of the following management is most likely indicated?

A. Back blows

B. Emergent ENT consultation 

C. Heimlich maneuver with patient supine

D. Needle cricothyrotomy

Teaching image

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• Herpes simplex virus is the most common infection associated with erythema multiforme.
• Hepatitis C can be associated with erythema multiforme, but that’s usually in the setting of active treatment with Telaprevir.
• COPD accounts for 70% of the cases of secondary spontaneous pneumothoraces.
• The incidence of secondary spontaneous pneumothoraces is three times greater in men than in women.
• In the setting of acute-onset heart block due to coronary occlusion, suspect a right coronary artery occlusion as this artery supplies the AV node in the majority of patients.
• Obesity may lead to a spuriously low BNP.
• A BNP < 100 can rule out heart failure, but an elevated BNP is not necessarily indicative of failure.
• In ACE inhibitor-mediated angioedema, an accumulation of bradykinin leads to swelling.  The swelling typically occurs in the face, but it can also lead to complications in the GI tract.
• Hereditary angioedema is caused by a deficiency or dysfunction of C1 esterase inhibitor.  Episodes are typically precipitated by stress or trauma.
• With ACE inhibitor-mediated angioedema, the treatment is cessation of the agent and supportive care. An ENT consult may be needed.  
• For hereditary angioedema, the treatment is with C1 esterase inhibitor replacement or with FFP if the inhibitor is not available.
• In the setting of an acute arterial occlusion, paralysis, and paresthesias require emergent surgical intervention.  Such findings usually herald more advanced disease.
• Do not forget the six Ps of acute arterial occlusion: paresthesias, paralysis, pallor, pulselessness, poikilothermia, and pain out of proportion to exam.
• Acute arterial embolisms should be managed by embolectomy, whereas in situ thromboses may respond to anticoagulation.
• Left ventricular thrombus formation after an MI is the most common source of arterial emboli.
• In cases of partial airway obstruction in children due to a foreign body, set-up for both direct laryngoscopy and cricothyrotomy while awaiting ENT arrival for foreign body removal in the operating room. Avoid agitating the child as changing positions may convert a partial obstruction to a complete obstruction.

That wraps up episode 15! What do you guys think of the pauses after questions? Let us know by emailing us at Roshcast@roshreview.com. Do not forget to check out the high-yield questions and explanations in the Rosh Review Emergency Medicine Qbank.

Until next time,
Jeff and Nachi

P.S. If you missed last week’s episode including frostbite, listen here.