Podcast Ep 20: Cocaine Chest Pain, Migraines, Hypothermia, & More

March 22, 2017

As knowledge increases, wonder deepens.

-Charles Morgan
Welcome back to Episode 20! We have a great episode lined up for you this week, again covering topics that run the gamut of Emergency Medicine. We are excited to say that we have covered over 100 questions in approximately five hours of Roshcast over six months! As always, send us any feedback or suggestions to roshcast@roshreview.com. Let’s get going with this week’s content!

  • TTP is treated with plasmapheresis. If plasmapheresis cannot be performed expediently, FFP can be used as a temporizing measure.
  • For any patient on warfarin with a life-threatening bleed, FFP, PCC, or Recombinant factor VIIa should be given. For a patient on aspirin with a life-threatening bleed, DDAVP should be given in addition to platelets.
  • For patients with intracranial hemorrhages, new evidence from the PATCH trial suggests that platelets may actually increase the risk of death and dependence, so such patients should only be given DDAVP.
  • Both Hemophilia A and B are X-linked recessive disorders.

Now onto this week’s podcast

Question 1

A 23-year-old man presents with chest tightness after intranasal cocaine use. Vital signs are HR 133, BP 155/95, and oxygen saturation 95%. ECG reveals sinus tachycardia with no ischemic changes. What medication should be administered?

A. Benzodiazepine

B. Beta-blocker

C. Calcium channel blocker

D. Naloxone

Teaching Image 1
Teaching Image 2

Question 2

Which of the following is the most common type of migraine headache?

A. Basilar-type migraine

B. Migraine with aura

C. Migraine without aura

D. Ophthalmoplegic migraine

Teaching Image 

Question 3

A 59-year-old man is found naked under a bridge. He is unresponsive and does not respond to painful stimulation. His rectal temperature is 32ºC. The patient is intubated for airway protection, warm blankets are placed, and active internal rewarming measures are initiated. The patient’s temperature slowly rises to 35ºC, but then begins to fall. Which of the following is most likely responsible for this phenomenon?

A. Cooling of blood during cardiopulmonary circulation

B. Equipment failure

C. Paradoxical splanchnic vasoconstriction

D. Return of cold blood to core from periphery

Teaching Image 

Question 4

Which of the following statements regarding drug exposure and overdose in pregnancy is true?

A. Gastric decontamination with charcoal or whole-bowel irrigation should be avoided in pregnancy

B. Iron crosses the placenta and causes direct fetal toxicity

C. Most antidotes should not be given in pregnancy due to the risk of fetal harm

D. Salicylate overdose is associated with poor fetal outcomes

E. The threshold to treat carbon monoxide poisoning is the same in pregnant and nonpregnant women

Teaching Image

Question 5

A 32-year old woman with HIV presents for the evaluation of a headache. She denies fever and her neurologic examination is normal. A CT scan of the head is performed and shown above. Which of the following is true regarding the finding on the CT scan?

A. It is caused by reactivation of a previous infection

B. It is transmitted through dog feces

C. The CD4 count is typically less than 50 cells/mm3

D. The organism is a common cause of meningitis

Teaching Image 

Question 6

A woman suffers from an acute attack of vertigo, nausea, and vomiting. You suspect viral labyrinthitis. Which of the following medications is the best choice in treating the vertigo?

A. Acyclovir

B. Phentermine

C. Prednisolone

D. Prochlorperazine

Teaching Image 

  • In the PATCH trial, platelets were shown to increase the risk of death in acute intracranial hemorrhage in patients on aspirin.
  • Cocaine chest pain should be treated with benzodiazepines to both relieve vasospasm and decrease sympathetic surge.
  • Beta-blockers should be avoided in those with cocaine chest pain due to unopposed alpha agonism.
  • The most common type of migraine is a migraine without an aura.
  • The classic migraine is a slow onset, unilateral, pulsating, headache with moderate to severe intensity. It may be associated with nausea, vomiting, photophobia, or phonophobia.
  • Migraines affect women twice as often as they affect men.
  • The most typical migraine auras are visual.
  • When actively rewarming a patient, a decrease in core temperature is common as cold blood returns from the periphery.
  • In hypothermia, expect a 2% increase in the hematocrit for every 1 degree Celsius drop in temperature.
  • Salicylate overdoses are associated with poor fetal outcomes as salicylates readily cross the placenta, causing acidosis, kernicterus, and prematurely closure of the ductus arteriosus.
  • The treatment for a salicylate overdose is gastric decontamination, urinary alkalization, and hemodialysis.
  • Indications for dialysis in a salicylate overdose are altered mental status, renal failure, pulmonary edema, rising levels despite alkalinization, coma, or clinical deterioration.
  • In carbon monoxide poisoning in pregnancy, the threshold for initiating hyperbaric oxygen therapy is lower as the half-life of carbon monoxide is almost 5 times longer in the fetus than in the mother.
  • Toxoplasmosis occurs due to reactivation of a prior infection in patients with HIV and a CD4 count less than 100. It is transmitted through cat feces and can cause encephalitis. Treatment is with pyrimethamine, sulfadiazine, and folinic acid.
  • Viral labyrinthitis should be treated with rest, hydration, antiemetics, vestibular depressants, and corticosteroids. Benzodiazepines may also be used.

That wraps up Episode 20. Don’t forget to follow us on Twitter @Roshcast for updates and high-yield EM pearls in 140 characters or less. We will primarily be posting on material that we have already covered on the podcast to add yet another element of spaced repetition. Be sure to take full advantage! And take a look at our new Teaching Image series on the blog. The first three posts are already up: Cardiac Tamponade, Tinea Versicolor, and Basilar Skull Fracture.

Until next time,
Jeff and Nachi

By Nachi Gupta, M.D., Ph.D., and Megha Rajpal, M.D.

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