364 Emergency Medicine
Localized reactions including erythema, swelling, and pruritus are com-
mon after intramuscular or subcutaneous injection. Anaphylaxis has been
described but is rare. Acetaminophen (b)has the principal side effect of
hepatotoxicity. In patients using it chronically without following dose-
based guidelines, liver damage is possible. (d)Caffeine is a methylxan-
thine. Side effects include palpitations, anxiety, tremulousness, and dry
mouth. Sumatriptan (e)has side effects related to the cardiovascular system.
They include hypertension and coronary artery vasospasm. Several cases of
myocardial infarctions have been observed after its use.
332.The answer is b.(Tintinalli et al, pp 1431-1434.)The clinical pre-
sentation is consistent with meningitis.The patient’s mental status has
declined between initial nursing assessment and the physician’s interview.
Delay of antibiotic therapy in order to first confirm the diagnosis with CSF
analysis may lead to increased mortality.
LP(a)performed even several hours after initiation of antibiotic ther-
apy is often still culture positive for the causative organism. Administration
of IV corticosteroids prior to antibiotic administration (c)has been shown
in some studies to reduce the mortality of patients with bacterial meningitis.
Their use in the ED for undifferentiated cases of meningitis has not been
sufficiently studied. Antipyretics (d)are used to reduce fever but will not
stop the primary pathologic process. Noncontrast head CT (e)should be
obtained prior to LP when question of mass effect or increased ICP might
lead to herniation from CSF removal. Antibiotic therapy should not be
delayed in cases of suspected meningitis for neuroimaging.
333.The answer is c.(Rosen, pp 1463-1464.)IIH is an idiopathic eleva-
tion of ICP. In the setting of a normal CT, the diagnosis is made by LP with
an elevated opening pressure often between 250 and 450 mm H 2 O. Patients
often experience complete relief of their symptoms with LPand return of
their ICP to levels < 200 mm H 2 O.
Corticosteroids (a)are controversial in the management of headache in
IIH, but many neurologists use them routinely. Mannitol (b)is an osmotic
diuretic that is used to acutely lower ICP, often in the setting of trauma to
prevent impending herniation. Its use is not recommended in the setting of
IIH. It should not be confused with acetazolamide, a carbonic anhydrase
inhibitor that works as a diuretic and is part of maintenance treatment for
IIH. Metoclopramide (d)is normally used as an antiemetic but is also highly
effective in the treatment of migraines. Ketorolac and other NSAIDs (e)are