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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients

Julien Guillaumin, DVM, DACVECC, DECVECC, The Ohio State University

Pharmacology & Medications

|November 2018|Peer Reviewed|Web-Exclusive

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients

Corticosteroids are indicated for many medical conditions, including immune-mediated diseases (eg, immune-mediated thrombocytopenia, immune-mediated hemolytic anemia) or anaphylaxis, but may be contraindicated in certain situations or may precipitate adverse events. Corticosteroids are also contraindicated in cases of congestive heart failure, diabetic ketoacidosis, and wound healing. The decision to use corticosteroids in high-risk patients is often made on a case-by-case basis. The following quiz presents 8 high-risk cases in which corticosteroids may or may not be indicated.

8  Questions
Multiple Choice Questions
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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients

Take this quiz by answering the following multiple choice questions.
1/8  Questions
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Nala, a 30 kg, 6-year-old spayed female Irish setter, is presented with severe facial swelling, attributed to an anaphylactic reaction to a vaccination. She receives 17 units of NPH insulin twice a day to manage diabetes mellitus diagnosed 2 years prior. Her diabetes has been challenging to control, and she suffered a diabetic ketoacidosis crisis 6 weeks prior to presentation. Physical examination reveals periocular bilateral facial swelling (Figure 1). Spot glucose measurement obtained on admission is 401 mg/dL.

Severe facial swelling as a result of reaction to vaccination
Severe facial swelling as a result of reaction to vaccination

FIGURE 1 Severe facial swelling as a result of reaction to vaccination

FIGURE 1 Severe facial swelling as a result of reaction to vaccination

An association between chronic administration of corticosteroids and diabetes mellitus has been suggested in dogs.

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
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Taurus, an 8-year-old neutered male domestic shorthair cat, is presented as an emergency for a 24-hour history of dyspnea. He has been treated with oral prednisolone at 2 mg/kg q24 hours for the past 6 months for diagnosed immune-mediated hemolytic anemia (IMHA). Initial physical examination reveals a grade III/VI heart murmur and bilateral pulmonary crackles.

Thoracic radiographs of the patient revealing congestive heart failure
Thoracic radiographs of the patient revealing congestive heart failure

FIGURE 2 Thoracic radiographs of the patient revealing congestive heart failure

Thoracic radiographs of the patient revealing congestive heart failure
Thoracic radiographs of the patient revealing congestive heart failure

FIGURE 2 Thoracic radiographs of the patient revealing congestive heart failure

FIGURE 2 Thoracic radiographs of the patient revealing congestive heart failure

In addition to a full workup and treatment for congestive heart failure, which would be the best corticosteroid therapy recommendation for Taurus?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
3/8  Questions
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Frank, a 10-year-old neutered male dachshund, is presented with pelvic limb ataxia of one week’s duration. Frank had been seen by another veterinarian 4 days prior to presentation and was administered a course of deracoxib (2 mg/kg PO q24h), but neurological deficits worsened. A general physical examination is unremarkable. A neurologic examination is suggestive of an ambulatory T3-L3 myelopathy with spinal hyperpathia.

The patient’s worsening pelvic limb ataxia and proprioceptive deficits, despite NSAID therapy
The patient’s worsening pelvic limb ataxia and proprioceptive deficits, despite NSAID therapy

FIGURE 3 The patient’s worsening pelvic limb ataxia and proprioceptive deficits, despite NSAID therapy

FIGURE 3 The patient’s worsening pelvic limb ataxia and proprioceptive deficits, despite NSAID therapy

Is initiation of corticosteroid therapy recommended for Frank?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
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Abner, a 4-year-old neutered male mastiff, is referred for severe thrombocytopenia (platelet count 2,000/μL) and presumptive severe GI bleeding. Physical examination reveals mild hypovolemic shock and severe melena. Regenerative nonhemolytic anemia at 17% hematocrit is also identified. Immune-mediated thrombocytopenia (ITP) associated with severe gastric bleeding is suspected.

Which of the following is most accurate?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
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Liza, a 10-year-old spayed Irish setter, is presented for jaundice and lethargy of a few days’ duration. She has been treated for several years with carprofen and gabapentin for chronic hip dysplasia and severe osteoarthritis. After examination, she is diagnosed with severe IMHA.

Slide autoagglutination test is positive, confirming IMHA
Slide autoagglutination test is positive, confirming IMHA

FIGURE 5 Slide autoagglutination test is positive, confirming IMHA

FIGURE 5 Slide autoagglutination test is positive, confirming IMHA

Which of the following is most accurate?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
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Greta, a 6-year-old spayed cat with a 2-year history of well-controlled diabetes mellitus, is presented in respiratory distress. A mild cough of several months’ duration worsened in the week prior to presentation and dyspnea developed 2 days before presentation. Physical examination reveals marked to severe respiratory distress with severe bilateral expiratory wheezes.

Thoracic radiograph of the patient presented with chronic cough and acute respiratory distress
Thoracic radiograph of the patient presented with chronic cough and acute respiratory distress

FIGURE 6 Thoracic radiograph of the patient presented with chronic cough and acute respiratory distress

FIGURE 6 Thoracic radiograph of the patient presented with chronic cough and acute respiratory distress

Given the association between corticosteroids and diabetes mellitus, are corticosteroids recommended to stabilize this patient?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
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Caesar, a 2-year-old intact male pitbull, is presented with severe burns from boiling oil (Figure 7). Three days after his first presentation, Caesar develops systemic hypotension refractory to fluid therapy. Septic shock is suspected and antibiotics are initiated, but the patient’s blood pressure continues to decrease despite increased doses of norepinephrine and vasopressin.

Patient showing burns from boiling oil that later developed into refractory septic shock
Patient showing burns from boiling oil that later developed into refractory septic shock

FIGURE 7 Patient showing burns from boiling oil that later developed into refractory septic shock

FIGURE 7 Patient showing burns from boiling oil that later developed into refractory septic shock

Critical illness-related corticosteroid insufficiency (CIRCI) is a concern in this patient, but, because corticosteroids are known to impair wound healing, should CIRCI treatment be withheld in this case?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
8/8  Questions
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Jersey, a 12-year-old spayed crossbreed dog, is presented as an emergency after becoming suddenly dyspneic after an episode of acute vomiting. She is diagnosed with aspiration pneumonia, but her hypoxemia is not responsive to oxygen. She is intubated and mechanical ventilation is initiated. Acute respiratory distress syndrome (ARDS) is diagnosed based on thoracic radiographs (Figure 8).

Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia
Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia

FIGURE 8 Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia

Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia
Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia

FIGURE 8 Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia

FIGURE 8 Thoracic radiographs revealed severe bilateral noncardiogenic pulmonary edema, suggestive of ARDS secondary to severe aspiration pneumonia

Is it likely that using corticosteroids for ARDS will worsen Jersey’s infection?

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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients
8/8  Questions
Multiple Choice Questions
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Quiz: Indicated Versus Contraindicated Corticosteroid Use in Emergency Patients

Final score
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ARDS = acute respiratory distress syndrome, CIRCI = critical illness-related corticosteroid insufficiency, IMHA = immune-mediated hemolytic anemia, ITP = immune-mediated thrombocytopenia

References

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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