(a)Vasopressor therapy should not be started until the patient receives at
least normal saline fluid boluses to achieve a CVP between 8 and 12 mm Hg
or to maintain a MAP of at least 65 mm Hg. (b)Packed RBCs can be trans-
fused if the central venous oxygen saturation (SvO 2 ) is less than 70%, and
the hematocrit is less than 30%. However, this occurs after fluid adminis-
tration.(d)A CVP of 8 to 12 mm Hg is the goal. Fluid should be administered
when the CVP is less than 8 mm Hg. (e)The femoral vein is not a suitable
location to place a central line in early goal-directed therapy because it does
not accurately measure the CVP.
169.The answer is d.(Tintinalli, pp 617-618.)Epididymitisis an inflam-
mation of the epididymis, often caused by age-dependent bacterial infec-
tion. Sexually transmitted diseases (STDs), such as gonorrhea and
Chlamydia,are most common in patients younger than 35 years, while uri-
nary pathogens, such as Escherichia coliandKlebsiella,are most common in
patients older than 40 years. Unlike testicular torsion, the onset of pain in
epididymitis is usually gradual and the cremasteric reflex is (usually?)
intact. Scrotal elevation may transiently relieve pain (positive Prehn sign).
Treatment includes bed rest, scrotal elevation or support when ambulating,
avoidance of heavy lifting, and antibiotics for infection.
(a)This patient may require pain medications but coverage with appro-
priate antibiotics will help relieve symptoms. While penicillin is appropriate
therapy for primary syphilis, this patient has epididymitis. (b)While scro-
tal elevation may be helpful, definitive treatment for epididymitis requires
appropriate antibiotic coverage. (c)Epididymitis must be differentiated
from testicular torsion, a true emergency. Testicular torsion is a twisting of
the testicle on its root, and often occurs during strenuous activity or as a
result of trauma. It is acute in onset and pain is not typically relieved with
scrotal elevation and the cremasteric reflex may be absent of the affected
side. Manual detorsion may be attempted, but an immediate Doppler ultra-
sound must be obtained to look for blood flow to the testicle. (e)Hydro-
cele is a fluid accumulation in a persistent tunica vaginalis owing to
obstruction, which impedes lymphatic drainage of the testicle. On physical
examination, transillumination may help confirm the diagnosis. Treatment
includes reassurance, and possibly surgical follow-up for drainage.
170.The answer is b.(Tintinalli, pp 614-615.)Fournier gangreneis a
polymicrobial necrotizing fasciitisof the perineal subcutaneous tissue
and male genitalia that originates from the skin, urethra, or rectum. It usually
192 Emergency Medicine