Podcast Ep 26: Retinal Detachment, Meningitis, Chicken Pox & More

There are two ways of spreading light: to be the candle or the mirror that reflects it.

-Edith Wharton

Welcome back to Episode 26! Remember to listen for a trauma ring tone and if you hear one send us the time via email or tweet us @Roshcast with the time you hear it. This week, we start out with a brief ultrasound review and then get into some ophthalmology, ID, and toxicology. We will discuss a challenging cyanide toxicity question thanks to a suggestion from one of our listeners. Hope you enjoy it!

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• Lung sliding on bedside ultrasound is a normal finding. Absence of lung sliding is indicative of a pneumothorax.
• A lines are a normal finding on lung ultrasound. They are horizontal lines that are reflections of the pleura. B lines are concerning for pulmonary edema and appear as “vertical headlights” throughout the thorax.
• Any pregnant patient with lower abdominal pain or vaginal bleeding who doesn’t already have a confirmed intrauterine pregnancy requires a pelvic ultrasound to rule out an ectopic pregnancy.

Now onto this week’s podcast.

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Question 1

A 72-year-old man complains of decreased painless vision in his left eye associated with flashing lights and floaters. Visual acuity in the left eye is 20/200 and in the right eye is 20/30. Which of the following is the most likely diagnosis?

A. Acute angle-closure glaucoma

B. Optic neuritis

C. Retinal detachment

D. Temporal arteritis

Teaching Image

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Question 2

What is the most common causative organism of meningitis in a 1-week-old child?

A. Group B streptococci

B. Haemophilus influenzae

C. Listeria monocytogenes

D. Staphylococcus aureus

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Question 3

A 17-year-old man presents to the ED 30 minutes after intentionally ingesting an unknown amount of drain cleaner. The active ingredient is sodium hydroxide; the pH of the product is 13. Upon arrival, the patient is afebrile, heart rate is 120 beats per minute, blood pressure 130/70 mm Hg, respirations 22 breaths per minute, and oxygen saturation 97% on room air. He appears uncomfortable and reports chest discomfort. There are superficial burns of the oral mucosa and inflammation in the posterior oropharynx, but he is in no respiratory distress. Which of the following is true regarding this patient’s care?

A. Activated charcoal should be administered because the patient presented within an hour of ingestion

B. Dilution with milk or water may be performed

C. Gastric lavage should be performed to prevent systemic toxicity

D. He should be kept NPO in preparation for endoscopy

E. Induction of vomiting with ipecac may be attempted

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Question 4

A 45-year-old man is rescued from a house fire. He was unresponsive at the scene and was intubated by paramedics. Upon arrival, he is afebrile, tachycardic to 130 with a blood pressure of 90/60. His arterial blood gas is significant for a pH of 7.16, a carboxyhemoglobin level of 20%, and a lactate level of 11.5 mmol/L. What is the most appropriate treatment for potential cyanide toxicity in this patient.

A. Administer hydroxocobalamin as a 5 g IV infusion

B. Administer sodium bicarbonate to correct the acidosis

C. Administer the cyanide antidote kit (amyl nitrate, sodium nitrite, sodium thiosulfate)

D. Arrange for the patient to receive immediate hyperbaric oxygen therapy

E. Hyperventilate the patient and maintain FiO2 at 100%

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Question 5

An 85-year-old man presents via ambulance after a reported fall. He is non-verbal, bed-bound, and incontinent of urine and stool at baseline. He requires round-the-clock care, which is primarily provided by his daughter, a retired nurse. There are also several grandchildren that assist with his care on a daily basis. The EMS team is concerned for elder abuse and alerts you of their concerns on arrival to the ED. Which of the following factors is associated with a greater likelihood of underlying elder abuse?

A. Daughter’s occupation

B. History of incontinence

C. Male sex

D. Support by the grandchildren

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Question 6

Which of the following is true regarding the characteristic rash of chickenpox?

A. Lesions appear over 2–4 weeks with multiple stages present at once

B. Lesions appear over 2–4 weeks with one stage present at a time

C. Lesions appear over days and fade by the third day

D. Lesions appear over days with multiple stages present at once

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• Retinal detachment is associated with painless monocular vision loss with floaters and flashing lights. The retina appears as a dull and gray. Retinal detachment is treated surgically or with laser therapy. Consult ophthalmology immediately.
• Acute angle closure glaucoma classically presents with painful monocular vision loss. The pupil would be fixed and mid-dilated with a hazy cornea and perilimbic injection.
• Optic neuritis is characterized by central vision loss with preserved peripheral vision. Patents may also report pain with eye movement and reduced color vision.
• Temporal arteritis is a vasculitis that causes monocular vision loss and is associated with unilateral headaches and polymyalgia rheumatica.
• In neonates, 75% of cases of meningitis are caused by Group B strep. Other causes include E. coli, Listeria, and other gram-negative bacilli. Treatment is with cefotaxime and ampicillin or gentamycin and ampicillin
• In infants, bacterial causes of meningitis additionally include S. pneumoniae, N. meningitidis, and H. influenzae. Treat this age group with vancomycin, ampicillin, and cefotaxime or ceftriaxone.
• In children 3 months to 18 years, the three most common causes of bacterial meningitis are S. pneumoniae, N. meningitidis, and H. influenzae. Treatment is with either ceftriaxone and vancomycin or cefotaxime and vancomycin.
• In adults 18 to 50 years old, S. pneumoniae and N. meningitidis, are the most common pathogens. Treat them with ceftriaxone and vancomycin.
• In those over 50, in addition to S. pneumoniae and N. meningitidis, gram-negative bacilli and Listeria are also more common cause of bacterial meningitis, so ampicillin must be added to the ceftriaxone and vancomycin.
• After an alkali ingestion, early endoscopy is critical as it determines the extent of the injury and helps guide management, disposition, and follow up decisions. All patients should be kept NPO following their ingestion.
• Cyanide toxicity can be treated by giving either hydroxocobalamin or with the traditional kit which includes a combination of amyl nitrite, sodium nitrite, and sodium thiosulfate.
• For fire victims who also have elevated carboxyhemoglobin levels, cyanide poisoning should be treated with hydroxocobalamin.
• In the traditional cyanide overdose kit, the nitrites cause a methemoglobinemia, regenerating the mitochondria, while the thiosulfate aids in excretion.
• Elder abuse can come in any form: physical, sexual, emotional, neglect, abandonment, and even financial, failure to recognize it can lead to significant morbidity and mortality.
• The lesions of chickenpox appear over days with multiple stages present at once. They first appear at the hairline and spread caudally.
• Chickenpox is caused by the varicella-zoster virus, or human herpesvirus type 3. Treatment is supportive with antipyretics, antipruritics, and analgesia.
• There are two vaccines for chickenpox – both are live attenuated vaccines and are recommended for all immunocompetent infants over the age of 1 and in all non-infected immunocompetent adults.

That wraps up Episode 26. As always, feel free to submit questions for us to review. Don’t forget to listen for the trauma phone ring tone in the coming weeks for a chance to win a Rosh Review Subscription. Remember to tweet us @Roshcast or email us at roshcast@roshreview.com the exact time you hear the ring to win the prize.

Until next time,
Jeff and Nachi