Year 3. Texas Tech: Saem Questions

Question 1

Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing’s sign is pain in the right lower quadrant upon palpation of the left lower quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip.

Answer

A. Vital signs are usually abnormal, even early in the course of acute appendicitis.

The answer is A. The presentation of acute appendicitis varies tremendously. Early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. Other variations in presentation include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.

Question 2

Rosving’s sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated.

Answer

E. Pain in the right lower quadrant when left lower quadrant is palpated.

The answer is E. Rosving’s sign is pain in the right lower quadrant when the left lower quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh rotation. All of these signs are associated with appendicitis. Murphy’s sign is cessation of inspiration during palpation of the right upper quadrant and is associated with acute cholecystitis.

Question 3

In establishing a differential diagnosis of abdominal pain, which of the following is true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating women with or without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant.

Answer

D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.

The answer is D. Pain prior to nausea and vomiting is often suggestive of a surgical etiology of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.

Question 4

Of the following pain patterns, which is the least likely associated with diagnosis of peptic ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal

Answer

C. unrelenting pain over a period of weeks

The answer is C. Pain from peptic ulcer disease typically occurs in periods of exacerbation and remission. Unrelenting pain over weeks or months should suggest an alternative diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some patients may also complain of chest or back pain. Pain is frequently severe enough to awaken patients from sleep in early morning hours but is often not present upon waking in the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.

Question 5

A 78 year old female presents to the E.D. with a sensation of left-lower quadrant abdominal pain, accompanied by some irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure. What is the most likely diagnosis?

A. ovarian cyst
B. volvulus
C. appendicitis
D. diverticulitis
E. gastroenteritis

Answer

The answer is D. A patient with this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular disease with inflammation (wall thickening and stranding).

Question 6

A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she’s tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non-bilious, however it is projectile in nature. What is the most likely condition in this patient?
A. viral gastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloric stenosis

Answer

E. pyloric stenosis

The answer is E. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an “olive” palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults).

Question 7

A 46 year old woman presents to the emergency department complaining of abrupt onset of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is pacing around the stretcher and appears extremely uncomfortable. She has never experienced this type of pain previously and denies fevers or other symptoms. Renal calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.

Answer

C. Helical CT scan greater than 95% sensitive and specific for renal calculi.

The answer is C. Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study.

Question 8

A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower quadrant pain associated with loose stools. He has had no fevers or bloody bowel movements. Similar symptoms in the past were self-limited. All vital signs lie within normal limits. Physical examination shows mild tenderness in the left lower quadrant, normal active bowel sounds and neither masses nor peritoneal signs. His primary-care physician can see him tomorrow in his clinic. What should be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
D. Admit for observation and serial examinations

Answer

B. Discharge home on high-fiber diet, laxatives and stool softeners

The answer is B. This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.

Question 9

You are treating a 25 year old male with the recent diagnosis of Crohn’s disease in the ED. Regarding Crohn’s disease, you know that:
A. Lesions are typically contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer

Answer

D. There is a small increased risk of colon cancer

The answer is D. Although Crohn’s disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as “skip lesions”) and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn’s such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.

Question 10

A 53 year old obese woman presents to the emergency department, accompanied by three of her children, complaining of severe abdominal pain that began this afternoon after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all of the following EXCEPT:
A. positive sonographic Murphy’s sign
B. pain in the right scapula
C. leukocytosis with left shift
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits

Answer

D. marked inguinal lymphadenopathy

The answer is D. This woman is likely suffering from acute cholecystitis. Predisposing factors include female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ pain and sonographic Murphy’s sign (inspiratory arrest, due to pain, while the ultrasound probe is positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal limits.

Question 11

A 25 year old female presents with epigastric pain radiating straight through to the back. Laboratory tests are notable only for markedly elevated amylase and lipase. An abdominal X-ray is taken (see Figure). Regarding this patient’s presentation, which of the following is most likely true?
[image]
A. The most likely explanation for her symptoms is gallstone-related pancreatitis.
B. She probably has an ulcer, since the laboratory results are nonspecific.
C. Alcohol use is only associated with pancreatitis in patients older than this woman, and who have been abusing alcohol for years.
D. The abdominal X-ray is concerning for early bowel obstruction.
E. The X-ray reveals that intrathoracic pathology is likely the cause of the patient’s symptoms.

Answer

A. The most likely explanation for her symptoms is gallstone-related pancreatitis.

The answer is A. The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient’s pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy, pancreatic carcinoma, atherosclerotic emboli, and scorpion bites.

Question 12

A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse after eating. On physical exam she has a Murphy’s sign. The most likely diagnosis is:
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
E. Mesenteric Ischemia

Answer

D. Cholecystitis

The answer is D. Right upper quadrant pain, fever and a Murphy’s sign suggests cholecystitis. Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy’s sign

Question 13

A 47 year-old male presents, confused, to the ED. He has limited ability to give a history. On physical examination of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall (see Figure). What is the most likely diagnosis?
[image]
A. Rocky Mountain spotted fever
B. necrotizing fasciitis
C. liver disease
D. lymphangitis
E. hyperthermia

Answer

C. liver disease

The answer is C. The patient’s palmar erythema, spider angiomata, and caput medusa (due to recanalization of the umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall venous engorgement, as well as ascites (another clue to the patient’s liver disease).

Question 14

A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is obtained. Which of the following is the most likely operative finding in this patient?
[image]
A. Inflamed appendix
B. Rectus sheath hematoma
C. Ruptured spleen
D. Small bowel obstruction

Answer

D. Small bowel obstruction

The answer is D. Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman’s history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology.

Question 15

All of the following factors predispose to cecal volvulus EXCEPT:
A. pregnancy
B. age 25-35
C. prior abdominal surgery
D. marathon running
E. severe chronic constipation

Answer

E. severe chronic constipation

The answer is E. Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle.

Question 16

A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient’s condition?
[image]
A. Etiologic agents of this condition include bacteroides, E. coli, Klebsiella, Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica.
B. Elevations of WBC, bilirubin, alkapine phosphatase and serum aminotransferases will be seen on laboratory studies.
C. Emergent percutaneous drainage in the emergency department is indicated.
D. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately.
E. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm.

Answer

C. Emergent percutaneous drainage in the emergency department is indicated.

The answer is C. The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess.

Question 17

Which of the following pairings of referred pain and causal disease is least likely to be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis

Answer

A. sacral pain—ovarian torsion

he answer is A. Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain.

Question 18

A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids

Answer

E. admission for intravenous antibiotics and fluids

The answer is E. For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis.

Question 19

Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting.
C. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy.
D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus.
E. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction.

Answer

D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus.

The answer is D. Over 90% of spontaneous esophageal perforations occur in the distal esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.

Question 20

Working in the ED, you have identified a bony object wedged in the
mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in:
A. Esophageal perforation and mediastinitis
B. Epiglottal edema and airway obstruction
C. The rapid development of xerostomia
D. Barrett’s esophagitis

Answer

A. Esophageal perforation and mediastinitis

The answer is A. The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation.

Question 21

A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces. He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12. His neuromuscular exam shows extremely rigid extremities, and his laboratory values are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine phosphokinase levels. What is the most likely explanation for these findings?
A. neuroleptic-induced acute dystonia
B. neuroleptic malignant syndrome
C. schizophrenia, catatonic type
D. tardive dyskinesia

Answer

B. neuroleptic malignant syndrome

The answer is B. Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient’s temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used. Tardive dyskinesia (choice A) is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the tongue or lips, mouth puckering, or flailing movements either of the extremities or of the spine. Neuroleptic-induced acute dystonia (choice C) is an acute spasm of a muscle or muscle group associated with the use of antipsychotic agents. It presents with patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia (choice D) is an extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia, catatonic type (choice B), a diagnosis of exclusion, usually does not present with this degree of impairment.

Question 22

A 25 year old man returns to the ED, 24 hours after being released from the hospital with a new diagnosis of schizophrenia. He has recently started to take haloperidal for his psychotic symptoms. In the ED he is noted to have involuntary contractions of the muscles of the face, a protruding tongue, deviation of the head to one side, and sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no electrolyte or hematological abnormalities. Of the following choices, the preferred medication for this condition is:
A. diphenhydramine
B. lorazepam
C. phenobarbital
D. metoprolol

Answer

A. diphenhydramine

The answer is A. Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs in up to 5% of patients. Dystonic reactions, which can occur at any point during long-term therapy and up to 48 hours after administration of neuroleptics in the emergency department, involve the sudden onset of involuntary contraction of the muscles in the face, neck, or back. The patient may have protrusion of the tongue (buccolingual crisis), deviation of the head to one side (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and increasing under emotional stress, which occasionally misleads emergency physicians to believe they may be hysterical in nature. Dystonic reactions should be treated with IM or IV benztropine (Cogentin®), 1 to 2 mg, or diphenhydramine (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near-immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms.

Question 23

A 70 year old male with acute delirium requires administration of haloperidol for agitation. Which of the following is a recognized side effect of haloperidol?
A. first degree heart block
B. nephrogenic diabetes insipidus
C. prolonged QT interval
D. transient hepatitis

Answer

C. prolonged QT interval

The answer is C. Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia

Question 24

A 19 year old woman is brought to the emergency department by her friends because she has been saying that she is a superhero and trying to run into traffic to prove that she is indestructible. The friends report that she has been using drugs but they do not know which ones. Which of the following pairs of ocular finding and recreational drug is commonly observed?
A. dilated pupils – heroin
B. internuclear ophthalmoplegia – marijuana
C. pinpoint pupils – amphetamines
D. vertical nystagmus – phencyclidine

Answer

D. vertical nystagmus – phencyclidine

The answer is D. Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple sclerosis. CN VI palsy is not associated with any specific drugs.

Question 25

A 42 year old former custodial worker presents stating, “I think that people can hear what I am thinking.” In the emergency department, he becomes extremely agitated and threatening, and his psychoses become more severe. In choosing an antipsychotic medication, which of the following would be the most appropriate choice?
A. haloperidol
B. chlorpromazine
C. thioridazine
D. ketamine

Answer

A. haloperidol

The answer is A. Haloperidol is the most studied high potency antipsychotic agent used in agitated patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Peak serum levels occur in about 30 minutes after IM dosing. Unlike thioridazine, haloperidol does not cause respiratory depression, has negligible anticholinergic side effects, and rarely causes hypotension. Although benzodiazepines can be used in the agitated patient, respiratory depression can occur, and close monitoring is essential.

Question 26

A 20 year old college student is brought to the emergency department by campus police after he was found by his roommate saying people in the TV were trying to kill him. Which of the following criteria is not an indication for admission?
A. first-time psychiatric episode
B. demonstrates risk for suicide
C. inadequate psychosocial support
D. lacks capacity to cooperate with treatment

Answer

A. first-time psychiatric episode

The answer is A. For an acute psychiatric episode, the first goal is medically stabilizing the patient. Subsequently, a patient who presents without previous history of a psychiatric episode does not necessarily need to be admitted. This, of course, depends on the identity and severity of the condition, and whether it can be treated in the emergency department.

Question 27

A 55 year-old male presents with new onset agitation and confusion. Which of the following medical histories would suggest a psychiatric (non-organic) cause?
A. History of diabetes mellitus only
B. History of alcohol abuse only
C. History of hypothyroidism only
D. History of chronic obstructive pulmonary disease only

Answer

C. History of hypothyroidism only

The answer is C. Although hyperthyroidism may result in an agitated state, hypothyroidism is not generally associated with violent behavior. All other answers are potentially treatable medical problems that could account for the presentation of an agitated or violent patient. After assuring the safety of all parties involved, the emergency department physician should rule out organic causes of agitation.

Question 28

In dealing with the potential violent patient, the emergency physician should:
A. Approach the patient in a calm, controlled and professional manner
B. Assume that the strength of the doctor-patient relationship will ensure safety
C. Deal with the patient in a isolated room to protect the patient’s privacy
D. Use a loud voice and threaten to call security if the patient becomes agitated

Answer

A. Approach the patient in a calm, controlled and professional manner

The answer is A. Excessive eye contact may be interpreted as a sign of aggression (answer A). Emergency physicians are encouraged to maintain intermittent eye contact with the patient and to keep a professional and calm demeanor. Also a physician should never deal with an agitated or violent patient alone in an isolated room (answer D). Doors should always remain open and exits should never be blocked. Ample security should be close at hand before interviewing the patient (answer E). Finally, involved parties are encouraged to remove any personal effects (e.g. neckties, necklaces, earrings, etc.) that could be used as a weapon by the violent patient.

Question 29

A 35 year-old male is placed on his back on the gurney in physical restraints for violent behavior. Which life-threatening complication can arise?
A. circulatory obstruction
B. Metabolic acidosis
C. Asphyxia
D. Rhabdomyolysis

Answer

B. Metabolic acidosis

The answer is B. Bruises and abrasions are the most common complication of physical restraints. After restraint application, patients need to be monitored frequently and positions changed to prevent neurovascular complications such as circulatory obstruction, pressure sores, and rhabdomyolysis. Positional asphyxia can arise when patients are placed into the prone or hobbled position. Protracted struggle against restraints can promote a significant metabolic acidosis that has been associated with cardiovascular collapse. Patients who continue to struggle with physical restraints should be chemically restrained as well

Question 30

Which medication is ideal for the agitated or combative patient?
A. Nitrous oxide
B. Hydromorphone
C. Haloperidol
D. Propofol

Answer

The answer is C. Drugs with a relatively short half-life allow for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed. Antipsychotics (such as haloperidol) and benzodiazepines (such as lorazepam) exhibit most of these characteristics and are commonly used in combination in the emergency department. The use of 5 mg of haloperidol IV/IM with 2 mg of lorazepam IV/IM, repeated every 30 minutes as needed, is recommended for the combative patient who does not have contraindications to these medications. Half doses should be used in the elderly.

Question 31

19 year old man is brought in to the emergency department by EMS after being
found obtunded in his apartment by a friend. No additional history is available. On arrival, the patient is minimally responsive with sonorous respirations and a palpable rapid pulse. The most appropriate initial diagnostic test would be
A. Arterial blood gas
B. Electrocardiogram
C. Fingerstick glucose
D. Urine drug screen

Answer

C. Fingerstick glucose

The answer is C. Hypoglycemia is a common and readily treatable cause for altered mental status. An ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities caused by respiratory depression. While a urine drug screen may show positives, it cannot quantitate the amount of a substance or the time period in which the exposure occurred so a positive screen may not reflect cause and effect. An EKG, while a part of a toxicology evaluation, is not an appropriate initiate screening test for an unstable patient until airway and readily reversible causes have been addressed.

Question 32

A 27 year old is found unresponsive in his car in the hospital parking lot and brought in by security. During your initial evaluation you find him to be cyanotic with pulse oximetry reading 82% on room air with a respiratory rate of 4 breaths per minute. Radial pulses are present at 120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an intravenous line due to extensive scarring of his arms. You are suspicious of an overdose, which medication would you want to rapidly administer as a potential antidote in this situation?
A. Glucose
B. Naloxone
C. Thiamine
D. Flumazenil

Answer

B. Naloxone

The answer is B. The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic pupils. In addition, intravenous drug users often use up their veins. While hypoglycemia can definitely cause a depressed mental status and needs to be assessed, it should not result in respiratory depression or miotic pupils. Thiamine is utilized to prevent Wernicke’s encephalopathy particularly in malnourished patients who present with hypoglycemia but is not an antidote per se. Flumazenil can be used to temporarily reverse the respiratory depression caused by benzodiazepines but also carries with it the risk of precipitating withdrawal and uncontrollable seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with altered mental status.

Question 33

A 53 year-old known alcoholic presents with agitation, vomiting and altered mental status. His fingerstick glucose is 148. His serum ethanol level is undetectable and his head CT is normal. An ABG shows a pH of 7.21, pCO2 of 34, pO2 of 98 on room air. His basic chemistry panel includes a sodium of 136, potassium 4.1, chloride 108, bicarbonate 14, BUN 12, creatinine 1.1. What substance are you concerned that he may have ingested
A. Ethylene glycol
B. Salicylates
C. Isopropyl alcohol
D. Methanol

Answer

C. Isopropyl alcohol

The answer is C. The patient is presenting with a non anion gap metabolic acidosis. Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis. Salicylates result in an anion gap metabolic acidosis with a superimposed respiratory alkalosis. The following mnemonic can be used to recall the common causes of an increased anion gap metabolic acidosis: CAT MUDPILES;

C - cyanide
A - alcoholic ketoacidosis
T - toluene
M - methanol
U - uremia
D - diabetic ketoacidosis
P - paraldehyde
I - isoniazid/iron
L - lactate
E - ethylene glycol
S - salicylates

Isopropyl alcohol causes a ketosis without an acidosis.

Question 34

In treating hepatitis secondary to alcoholic liver disease, all of the following are true EXCEPT:
A. Treatment is primarily supportive including fluids and electrolyte correction.
B. Glucose should be administered prior to thiamine to avoid precipitating acute Wernicke’s encephalopathy
C. Magnesium replacement should be initiated empirically except in the setting of contraindications such as renal failure or hypermagnesemia.
D. Coexisting gastritis should be sought out and treated appropriately.
E. Nutritional status should be assessed with attention to possible protein restriction.

Answer

B. Glucose should be administered prior to thiamine to avoid precipitating acute Wernicke’s encephalopathy

The answer is B. Alcoholics often have low thiamine levels due to poor nutrition, and low glucose levels due to the suppression of gluconeogenesis by alcohol. However, thiamine should always be replaced prior to glucose to avoid the potential complication of precipitating Wernicke’s encephalopathy. Magnesium levels may appear normal on laboratory testing, but alcoholics typically have low magnesium stores and should be given magnesium empirically unless contraindications for magnesium exist. Alcoholics should also be evaluated for gastritis and overall nutritional status and should be referred appropriately.

Question 35

A 45 year old man is brought to the E.D., with markedly altered mental status as reported by someone who stays with him at a homeless shelter. The patient is very confused and obtunded, and unable to provide a cogent history; the person who brought him to the E.D. notes the patient has a “drinking problem.” The patient’s vital signs are normal, except for a respiratory rate of 22. As he lays in the stretcher, his appearance is as depicted in the Figure. Of the following choices, which physical finding is most likely to be present on physical examination?
[image]
A. Homan’s sign
B. anterior chest pain upon leaning forward, which is relieved by lying flat
C. dendritic rash on the posterior thorax, with a sentinel lesion noted on the left shoulder
D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion
E. increase in systolic blood pressure by more than 10 mmHg with inspiration

Answer

D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion

The answer is D. This patient has marked ascites (which may incidentally account for his mild tachypnea due to impairment of respiratory excursion). The most likely explanation given the limited information available is liver disease, and asterixis (“liver flap”) as described in choice D is a likely marker of advanced hepatic failure.

Question 36

A 60 year old male presents with new onset confusion. Which of the following suggests a functional, as opposed to an organic etiology?
A. abnormal vital signs
B. acute onset
C. auditory hallucinations
D. disorientation

Answer

C. auditory hallucinations

The answer is C. The other findings are all characteristic of organic confusional states. Hallucinations can occur with both organic and functional causes of confusion. Hallucinations associated with organic confusion may be visual, tactile, or auditory. Hallucinations in patients with functional disease tend to be auditory.

Question 37

Delirium is defined as:
A. a stressed psychological state resulting from extreme emotional stimulus
B. abnormal behavior associated with decreased alertness and decreased psychomotor activity
C. abnormal behavior accompanied by hallucinations, occurring in an oriented patient
D. a global inability to relate to the environment and process sensory input

Answer

D. a global inability to relate to the environment and process sensory input

The answer is D. Alterations in mental status resulting from extreme emotional stimulus would usually be functional abnormalities. Patients with delirium manifest increases in alertness and psychomotor activity. Delirium is more than simple alteration of mental status. Delirium is an organic confusional state. Patients with delirium may have hallucinations, but patients who are oriented are more likely to have functional causes for altered mental status.

Question 38

Which of the following statements regarding psychotic behavior is true?
A. Brief psychotic episodes, often precipitated by events such as death of a loved one, can be characterized by extremely bizarre behavior and speech
B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary
C. Delusional disorder usually results in impairment in daily functioning
D. Schizophreniform disorder is present when a patient meets the diagnostic criteria for schizophrenia but the process has been present for less than one year

Answer

B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary

B. Psychosis can be limited to nonbizarre delusions; patients with this disorder (delusional disorder) rarely have impairment in daily functioning. Fixed, false beliefs that are not held by others with a patient's cultural background are characteristic of delusional thinking.

Question 39

A 75 year old female is brought the to emergency department by a family member with a history of progressive forgetfulness and confusion. She has a history of dementia. The most common cause of dementia in the elderly patient is:
A. Alzheimer’s disease
B. Parkinson's disease
C. Pick’s disease
D. Vascular dementia

Answer

A. Most dementia is Alzheimer’s type. The second most common cause of dementia is vascular dementia, which accounts for 10 to 20% of all dementias. Primary degenerative dementias include Alzheimer’s disease, vascular dementia, subcortical dementias involving the basal ganglia and thalamus (e.g., progressive supranuclear palsy, Huntington’s chorea, Parkinson’s disease), and Pick’s disease, also known as dementia of the frontal lobe type. Smaller percentages are attributable to causes such as anoxic encephalopathy, hepatolenticular degeneration, tumors, and slow virus infections.

Question 40

A 65 year old male is brought to the emergency department after he was found wandering on the street. He is unkempt and confused. A diagnosis of delirium, rather than dementia, is more likely if which of the following is true?
A. there has been a slow progressive loss of memory
B. the sleep-wake cycle is unaffected
C. there is a change in the level of consciousness
D. the confusion is worse during the day

Answer

C. there is a change in the level of consciousness

The answer is C. Patients with delirium have disturbances in consciousness, cognition, and perception. These disturbances tend to occur over a short period of time (hours to days). The delirious patient may be somnolent or agitated. Thought process may be mildly disturbed or grossly disorganized. The clinical presentation may be subdued or explosive, and the course can fluctuate over minutes to hours. The patient’s sleep-wake cycle may be altered or reversed; agitation is often present during the night. An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity.

Question 41

An 80 year old nursing home patient is brought to the emergency department with an acute onset of confusion. Which of the following metabolic abnormalities is the most likely explanation?
A. hypocalcemia
B. hypokalemia
C. hypernatremia
D. hyperphosphatemia

Answer

C. hypernatremia

The answer is C. The differential diagnosis of acute confusional states is lengthy. It includes many metabolic/nutritional abnormalities including hypoglycemia, hypo-/hypernatremia, and hypercalcemia. Hypokalemia alone, however, is not a common cause of altered mental status.

Question 42

Which factor is least reliable in differentiating between organic and inorganic causes of confusion?
A. acute versus chronic onset
B. Vital sign abnormalities
C. Presence of attention deficit
D. Signs of trauma

Answer

C. Presence of attention deficit

The answer is C. Presence of an attention deficit is common to all confusional states. All the other options may be used to differentiate organic versus non-organic causes of confusion. Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs. Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions.

Question 43

With regard to specific causes of hypertension, which of the following is true?
A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible
B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours
C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible to reduce the risks of worsening neurological deficit
D. Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension
E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients

Answer

A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible

The answer is A. Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over hours; however, encephalopathy due to hypertension is more likely reversible than encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is particularly critical for patients with strokes. Laboratory analysis can be important in cases of hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses such as the HELLP syndrome).

Question 44

A 29 year old woman is found seizing by her husband and is rushed to the emergency department. On presentation, she is noted to have a BP of 162/112, is still seizing, and looks puffy all over. Her husband tells you that they are expecting their first child in a few months. Which of the following is the next best step in this patient’s care?
A. Control the seizures with magnesium sulfate.
B. Draw blood to check CBC, LFT’s, BUN, and creatinine.
C. Notify the labor floor that the patient is in the emergency department.
D. Perform a CT scan of head if seizures persist.
E. Start hydralazine to decrease the patient’s blood pressure.

Answer

A. Control the seizures with magnesium sulfate.

The answer is A. Antihypertensive therapy is only indicated in eclampsia if the diastolic blood pressure remains > 110 mm Hg after seizures are controlled because rapid lowering of blood pressure can result in uterine hypoperfusion. All the other choices (A-D) are appropriate in the management of the patient with eclampsia.

Question 45

Which of the following is not a feature of febrile seizures?
A. generalized tonic-clonic seizure
B. duration less than 15 minutes
C. associated with a rapid rise in body temperature
D. occurs in children ages 3 months to 5 years
E. associated with postictal state of 30 minutes

Answer

E. associated with postictal state of 30 minutes

The answer is E. Febrile seizure is not associated with a postictal period. The child usually rapidly regains alertness. Intracranial mass or infection should be a concern if the duration of seizure is greater than 15 minutes or if altered mental status persists after the cessation of seizure activity.

Question 46

A 47 year old man with a history of alcohol abuse presents to the emergency department after having a seizure. His past includes both seizures and blackouts. His last alcoholic drink was the previous evening. This morning he experienced palpitations, diaphoresis, and dizziness before losing consciousness and having a seizure lasting under a minute. Which of the following is a true statement with regard to alcohol and its association with seizures?
A. In people with an underlying seizure disorder, excessive alcohol intake is a risk-factor for seizure due to increased likelihood of head injury, predisposition to metabolic disorders, and lowered seizure threshold.
B. Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol and its metabolites.
C. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal syndrome.
D. All of the above statements are true.
E. All of the above statements are false.

Answer

D. All of the above statements are true.

Question 47

A patient with a ventriculo-peritoneal shunt presents to the E.D. with lethargy and vomiting. A CT scan obtained emergently (see the Right image in the Figure) is compared with a CT scan (see the Left image in the Figure) from a month ago. What is the diagnosis?
[image]
A. encephalitis
B. meningitis
C. pseudotumor cerebri
D. hydrocephalus and shunt malfunction
E. subarachnoid hemorrhage

Answer

D. hydrocephalus and shunt malfunction

The answer is D. The two CT scans demonstrate interval failure of the shunt to drain CSF.

Question 48

A 68 year old diabetic male, previously living independently, is brought in by his family. He has been acting abnormally for two days. The family reports he is awake all night and sleepy during the day. He is confused about where he is and the time of day, and sometimes doesn’t recognize his daughter and son-in-law. At other times he appears and acts almost normally.
Which of the following is true regarding his condition?
A. Infection is an unlikely cause of his condition unless his temperature is > 102° F.
B. Dementia is the most likely cause of his condition and the family must be counseled about the future course of the disease.
C. Medications are an unlikely cause of this condition in the elderly.
D. Patients can be agitated and combative, or calm and quiet in this condition.
E. Treatment includes maximizing sensory input.

Answer

D. Patients can be agitated and combative, or calm and quiet in this condition.

The answer is D. The scenario describes a patient with delirium, a condition in which patients may be agitated and combative, or calm and quiet. The most common cause of delirium in the elderly is medications, accounting for 22-39% of cases. Infection and metabolic abnormalities are other common causes, and delirium may be the first indication that an infection is present. An elderly patient with delirium resulting from an infection may have a normal temperature, a low temperature, or a high temperature. Delirium is characterized by an acute onset of a disturbance in level of consciousness, cognition and attentiveness. It has a fluctuating course, and alterations in sleep-wake cycles are common. Dementia, in contrast, has a slower course, that is gradually progressive over months to years, and consciousness is preserved. In addition to correcting the underlying cause, it is important to minimize stimulation, because the patient with delirium has difficulty processing stimuli.

Question 49

The chest X-ray in the Figure was taken in an intoxicated patient who is conversant, but an unreliable historian. The X-ray findings are best described as indicating:
[image]
A. Esophageal foreign body
B. Intratracheal foreign body
C. mediastinitis from esophageal perforation
D. normal chest

Answer

A. Esophageal foreign body

The answer is A. The film reveals a classic appearance of a round foreign body (in this case, a pull-top from a beer can) in the esophagus. The foreign body appears to lie outside the tracheal shadow. There is no sign of mediastinal air (which would be expected with penetrating trauma). The X-ray reveals no signs of mediastinitis, but the risk of esophageal perforation and ultimate mediastinitis prompts endoscopic intervention in this patient.

Question 50

An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient?
A. No specific treatment required
B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up
C. Placement of tooth fragment in saline gauze, outpatient dental follow-up
D. Immediate dental consult to avoid abscess formation
E. Replace fractured piece and place acrylic splint

Answer

D. Immediate dental consult to avoid abscess formation

The answer is D. Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation.

Question 51

A 22 year old man is punched in the nose during a fight. He presents to the emergency department with obvious nasal bone deformity. Pressure controls the bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact vision and extraocular movement. The oropharynx and mandible are unremarkable. Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step?
A. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum
B. Plastic surgery consult for immediate reduction of nasal fracture
C. Facial CT scan to rule out more serious facial fractures
D. Incision and drainage of the septal hematoma followed by nasal packing
E. Needle aspiration of the septal hematoma

Answer

D. Incision and drainage of the septal hematoma followed by nasal packing

Question 52

A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries?
A. Inferior orbital wall fracture
B. Superior orbital rim fracture
C. Ethmoid fracture
D. Zygomatic arch fracture
E. Inferior orbital rim fracture

Answer

A. Inferior orbital wall fracture

The answer is A. The patient most likely has an orbital floor fracture with entrapment.

Question 53

A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay. What should be the first step in the management of this patient?
A. Administration of phenytoin 1000mg IV
B. Administration of mannitol 50 g IV
C. Rapid sequence intubation using paralytic agent
D. Emergency craniotomy
E. Administration of 2 liters NS bolus

Answer

C. Rapid sequence intubation using paralytic agent

The answer is C. The airway should be managed as the first priority in this patient. The other maneuvers may be helpful but are secondary to securing an airway and providing oxygenation/ventilation. Airway comes first!

Question 54

A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F, BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a
tension pneumothorax. Of the following, which is the most appropriate next step in this man’s care?
A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Transfusion of 2 units of O-negative packed red blood cells
C. Performance of a chest CT scan to further delineate the pathology
D. Placement of a needle decompression device, followed by repeat CXR

Answer

D. Placement of a needle decompression device, followed by repeat CXR

This patient needs emergent chest decompression and this is rapidly done by needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime. Transfusion of blood does nothing to correct the physiology of a tension pneumothorax

Question 55

The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O’Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination

Answer

E. two-point discrimination

The correct answer is E. Light touch is a good screening test, but two-point discrimination is more sensitive and should be used routinely in evaluating injuries to digits. The O’Riain wrinkle test involves placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the nerve is intact.

Question 56

Which is not part of the Ottawa ankle rules?
A. inability to walk 4 steps at the time of the injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus
E. tenderness over the talus

Answer

E. tenderness over the talus

The correct answer is E. The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed.

Question 57

Choose the INCORRECT statement regarding thoracentesis from the anterior approach (needle decompression):
A. An upright chest X-ray should always be performed following a thoracentesis to confirm the successful relief of a tension pneumothorax and the absence of hemothorax or other complications.
B. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib.
C. The recommended insertion site is the second intercostal space, midaxillary line.
D. After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax.
E. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube should be placed as soon as possible.

Answer

C. The recommended insertion site is the second intercostal space, midaxillary line.

The answer is C. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin (answer B). The remaining answers are all correct statements regarding thoracentesis (answers C, D, E).

Question 58

In a patient with a suspected ruptured globe from penetrating trauma to the eye, all of the following should be performed EXCEPT:
A. ascertainment of intraocular pressure via tonometry
B. administration of broad spectrum antibiotic therapy
C. visual acuity assessment
D. ascertainment of tetanus status
E. ophthalmology consultation

Answer

A. ascertainment of intraocular pressure via tonometry

The answer is A. Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury. Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical.

Question 59

Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement. What is the most likely cause of his symptoms?
A. retrobulbar hematoma
B. chemosis
C. hyphema
D. orbital blow-out fracture
E. ruptured globe

Answer

A. retrobulbar hematoma

The answer is A. Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement. Yet, they do not present with proptosis – unless complicated by retrobulbar pathology.

Question 60

Following a brawl at a local bar, a gentleman presents with an impressive right-sided periorbital ecchymosis. All of the following physical examination findings would suggest an orbital blowout fracture EXCEPT:
A. diplopia with upward gaze
B. right-sided infraorbital subcutaneous emphysema
C. right-sided epistaxis
D. proptosis
E. anesthesia of the right infraorbital region

Answer

D. proptosis

D. Orbital blowout fractures classically involve the maxillary or ethmoid sinus and consequently often cause either epistaxis (through the connection of the maxillary sinus with the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral infraorbital region. If the inferior rectus muscle gets trapped within the fracture of the inferior orbital wall, patients will be unable to look upward causing diplopia with upward gaze. Orbital blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should prompt physicians to suspect the possibility of a retrobulbar hematoma.

Question 61

The patient depicted in the figure presents to the ED just after sustaining a pellet-gun wound to the right eye. What do the arrows most likely indicate?
[image]
A. hyphema
B. iritis
C. keratitis
D. pterygium
E. hypopion

Answer

A. hyphema

The answer is A. The patient has a fluid level/meniscus in the anterior chamber, that is most likely indicative of hyphema (collection of blood). Hypopion (collection of purulent material) is less likely in this setting, and keratitis (corneal inflammation) and iritis (inflammation of the iris) are not indicated by the arrows. A pterygium is a growth which is visible on the sclera, and which crosses the limbus onto the cornea.

Question 62

The patient in the figure sustained minor blunt trauma to the eye, and has a normal head/orbital computed tomography (CT) scan. Ophthalmological examination is normal, other than the blood as shown in the figure (the blood does not cross the limbus). Of the choices below, which diagnosis is the most likely based upon the figure?
[image]
A. foreign body
B. ruptured anterior chamber
C. subconjunctival hemorrhage
D. hyphema
E. globe rupture

Answer

C. subconjunctival hemorrhage

The answer is C. The subconjunctival blood as depicted in this patient, can be expected to resorb without intervention over days to weeks. The figure does not suggest rupture of anterior chamber or hyphema; globe rupture and foreign body are less likely given the normal examination and CT scan.

Question 63

A patient presents with a self-inflicted wound, with resultant loss of vision in the right eye. With regard to the figure, which of the following statements is most likely true?
[image]
A. Medial canthotomy should be performed immediately.
B. If ambulance providers contact medical control about a patient with this injury, they should be directed to replace the globe back into the orbit.
C. Search for other self-inflicted injuries (or ingestions) is paramount.
D. Life-threatening hemorrhage is a major risk with this injury.
E. The patient will probably recover visual function.

Answer

C. Search for other self-inflicted injuries (or ingestions) is paramount.

The answer is C. The patient is unlikely to recover any visual function, which renders more important parallel efforts to identify (treatable) injuries or ingestions that are less obvious than the ocular avulsion. Lateral (not medial) canthotomy is an emergency procedure that may be indicated in some patients with ocular injury and retrobulbar hematoma (with resultant traction on the optic nerve), but the procedure is unlikely to help this patient. Since manipulation of an injured globe risks further trauma and extrusion of vitreous humor, prehospital recommendations for eye trauma are limited to protection of the injured eye and expedited transport to definitive care. Life-threatening hemorrhage is not a major risk with this type of injury.

Question 64

What is the most common cause of death in Americans aged 20 to 40 years?
A. Drug overdose
B. Trauma
C. Cancer
D. AIDS-related illness
E. Pneumonia

Answer 64

E. Mother pulseless and apneic for 2 minutes’ duration and still in arrest; fetal heart tones of 100 beats per minute

The answer is E. Though emergency C-section after maternal death is a rarely indicated procedure, rapid intervention (within minutes) of maternal demise has resulted in viable births.

Answer 65

A. Administration of IV steroids and ordering of cervical MRI

The answer is A. Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease. The ligamentum flavum buckles into the cord, resulting in a contusion of the cord’s central portion.

Answer 66

D. L4-L5

The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5.

Answer 67

A. Transverse process fracture

The answer is A.
A transverse process fracture involves only one of the supporting spinal columns (the posterior column) and is therefore stable.

Answer 68

B. Angiography, esophogram, and admission for observation

The answer is B. Zone I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted.

Answer 69

E. All of the above

The answer is E. The diaphragm can rise to as high a level as the fourth intercostal space and can be injured by stab wounds at this level. Unsuspected injuries are common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-abdominal injuries and can distract a patient from such an injury. Therefore, all of these patients need an evaluation of their abdomens.

Answer 70

C. 24 year old man with liver laceration; hemodynamically stable

Answer 71

E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum.

The answer is E. Diagnostic peritoneal lavage is extremely sensitive for the detection of hemoperitoneum and can lead to many negative laparotomies. Neither bedside ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury.

Answer 72

A. CT abdomen / pelvis with IV and transurethral contrast

Answer 73

E. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60

The answer is E. Emergency Department thoracotomy is a controversial procedure. When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt trauma has a dismal success rate and is generally not considered an indication for ED thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An awake patient with a relatively normal blood pressure does not need one performed in the Emergency Department. An unconscious and pulseless patient with a detectable blood pressure has the best chance for survival.

Answer 74

A. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable

Answer 75

E. Left-sided chest tube, portable chest x-ray, and abdominal CT scan

Answer 76

E. Decreased sensation over the thenar eminance

The answer is E. This finding is due to median nerve injury.

Answer 77

C. Femoral neck fracture

The answer is C. Patients with dislocation tend to have internal (not external) rotation.

Answer 78

B. Immediate reduction in emergency department under conscious sedation without X-rays

The answer is B. A knee dislocation frequently injures the popliteal artery, threatening the survival of the limb. Immediate reduction for the dislocation is warranted to attempt to restore flow through the artery, and should be attempted by the ED physician without waiting for orthopedics. Transport to the OR is an unnecessary delay, and while arteriography will be indicated, the most urgent priority is restoring blood flow.

Answer 79

A. Fluid (blood) in the sinuses

The answer is A. Blood in the sinuses can be a useful indirect indicator of facial fracture.

Answer 80

C. Eikenella corrodens

The answer is C. There are many species of bacteria in the human mouth, and Eikenella corrodens is an aggressive one, frequently causing infection in the first 24 hours after injury.

Answer 81

C. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination.

The answer is C. The overall evidence points to a superior-medial to inferior-lateral wound trajectory, with subcutaneous ecchymosis indicating the missile track and the more ragged wound at the inferior-lateral (groin) region most likely an exit wound. However, though wound description is very important for the emergency physician (both as a guide to injury evaluation and also as an early characterization of wounds, before interventions such as wound exploration obscure physical findings), speculation as to whether wounds are entrance or exit wounds are best left off of the E.D. record. Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus, the best course is a meticulous description (or photograph) of the wound, noting items such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to expansion of gun barrel gases in a contact wound) but leaving interpretation of the physical evidence to forensics experts. The wound characteristics are not consistent with self-inflicted injury, though the ED physician should have a low index of suspicion for psychiatric consultation when there is doubt on this subject.

Answer 82

A. 100% oxygen

The answer is A. An occult pneumothorax may resorb with only oxygen administration, not requiring invasive management. Needle decompression is used for tension pneumothorax, and heliox may be used for reactive airway disease to reduce resistance to flow.

Answer 83

B. Free intraabdominal fluid

Answer 84

D. The patient likely has paralysis and loss of sensation to pain and temperature bilaterally below the lesion

The answer is D. Answer A describes central cord syndrome, typically caused by hyperextension. Answer C describes Brown-Sequard Syndrome, caused by hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to the anterior spinal artery; patient with this cord syndrome often have more than just sensory symptoms.

Answer 85

D. Persistent pneumothorax

The answer is D. The chest CT shows a chest tube in place on the right, with incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a large right pulmonary contusion, as well as pneumothorax and small hemothorax on the right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not the right).

Answer 86

C. C5/C6

he answer is C. The patient has anterior displacement of C5 on C6.

Answer 87

A. Deep burns

The answer is A. Patients with high voltage injury commonly present with devastating burns. The burns are most severe at the source and ground contact points. The most common sites of contact with the source include the hands and the skull. The most common areas of ground contact are the heels. Deep burns occur in less than 5% of lightning injuries. Electrical injuries may cause four types of superficial burns or skin changes: linear burns, punctate burns, feathering, or thermal burns. Loss of consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage electrical injury and lightning injury. Electrolyte abnormalities are not common in either injury.

Answer 88

D. The involved areas of this 3rd-degree burn would be expected to be mostly insensate

The answer is D. The answer is D. 3rd-degree burns are often insensate; withholding pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic antibiotics are not recommended.

Answer 89

D. The patient has a history of Crohn’s disease

The answer is D. In SAD CAGES is a screening mnemonic for symptoms, not causes, of major depression. Depression is more common in patients with history of other medical illnesses, some of which may actually cause depressive symptoms. As compared with major depression, dysthymic disorder is a more chronic, and less severe, form of depressive illness.

Answer 90

D. interferon alfa therapy

The answer is D. Interferon alfa, an important cytokine in the early immune response to viral infection, has both antiproliferative and antiviral properties. It is the only therapy approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa has been associated with high rates of central nervous system side effects, including anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal ideation. Clinicians should always look up the side effects of their patients’ medications, especially unfamiliar drugs. This can both expedite diagnosis of drug-induced complications and prevent them with appropriate pretreatment. Pretreatment with a selective serotonin reuptake inhibitor appears to be an effective strategy to minimize depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver disease can both be difficult diseases to live with, however, these conditions are not known to significantly increase a patients’ risk for new suicidal ideation. Depression is not a known side effect of ribavirin treatment. Although males have a higher percentage of successful suicide attempt than females, females have a much higher incidence of suicide attempt and ideation than males overall.

Answer 91

D. Family sitters provide the best option for close observation of suicidal patients since they often have a calming influence on the patient.

The answer is D. For any patient presenting with suicidal ideation, the emergency department physician must first stabilize medical condition as most attempts involve minor injury or drug overdoses treatable by emergency room staff. Secondly, all objects and substances should be kept strictly out of reach of the suicidal patient. Once stabilized these patients may be kept under direct supervision. It is not recommended that family members provide the direct supervision because of a possibility of collaboration between family and patient to leave the hospital. In this event, or even before coming into the hospital, all law enforcement has the right to bring into custody any patient at risk of harming self or others.

Answer 92

B. African-American males

The answer is B. The epidemiology of suicide varies according to age, gender and race. Overall, men have higher rates of completed suicide and women have greater numbers of suicide attempts. Suicide risk among men shows a bimodal distribution with increased risk between the ages of 15 and 24 and after age 65. Suicide risk among women peaks after age 60. People who suffer from a chronic disease such as AIDS are at increased risk for committing suicide. The dramatic increase in suicide rates among adolescents is thought to be due to changing demographics and greater access to firearms. Underlying psychiatric illness increases a person’s risk of suicide. Major depression, bipolar, borderline personality disorder, schizophrenia, and panic disorder are all associated with increased suicide rates. Of note, One study demonstrated that 40% of people who suffer from panic attacks would attempt suicide at some point in their lives. Studies have demonstrated that the presence of breast implants portends a higher risk of suicide.

Answer 93

B. Patient’s behaviors and actions pose an imminent harm to self

he answer is B. Physical and chemical restraints should only be used when verbal tactics have failed and when the patient is an immediate threat to himself, others or the integrity of the emergency department. From a medico-legal standpoint, clear documentation is very important when a decision is made to apply restraints. Answers A, C, D, and E are all valid reasons for physical or chemical restraints.

Answer 94

C. panic disorder

The answer is C. Most people who commit suicide suffer from either alcoholism or a diagnosable psychiatric illness. 15-20% of people with major depression and 10% of people with schizophrenia will commit suicide. Up to 40% of people with panic disorder will attempt suicide at some point in their lives. PTSD also carries an increased risk.

Answer 95

C. separated, divorced or widowed

The answer is C. Being separated, divorced or widowed is an important but less significant factor in determining suicide risk and so is assigned 1 point on the suicide scale. All the others are high-risk factors and are each assigned 2 points on the suicide scale. A score of 6 or more has a sensitivity of 94% and a specificity of 71% compared with formal psychiatric evaluation to identify the need for hospitalization in patients who present immediately after a suicide attempt.

Answer 96

A. an act of slowly killing oneself by nonviolent means, such as starvation or non-compliance with essential medical treatment

The answer is A. "Silent Suicide" is most common in elderly patients and frequently goes unrecognized. Such patients may present to the emergency department repeatedly because of non-compliance with treatment of their medical disorders. "Occult Suicide" is applied to self-destructive acts disguised as accidents and should be suspected in those who have "accidental" self-inflicted gun shot wounds, and in those who "unintentionally" overdose, or who fall from a height. "Chronic Suicidal Behavior" consists of recurrent self-destructive acts. "Mass or Group Suicide" is suicide involving a number of people. "Parasuicide" is an attempted suicide, which is seen more as a gesture than a serious act.

Answer 97

D. Patient who ingested a “bottle” of tylenol

The answer is D. Routine toxicological screening is unnecessary in the evaluation of suicidal patients in whom there are no clinical indications for such testing. With the exception of acetaminophen, essentially all patients with dangerous overdoses and poisoning will demonstrate clinical signs within several hours of ingestion. History, physical examination, and risk determination of suicide, however, is part of the routine evaluation of the suicidal patient.

Answer 98

A. Patients who are elderly and Caucasian

The answer is A. TRoutine toxicological screening is unnecessary in the evaluation of suicidal patients in whom there are no clinical indications for such testing. With the exception of acetaminophen, essentially all patients with dangerous overdoses and poisoning will demonstrate clinical signs within several hours of ingestion. History, physical examination, and risk determination of suicide, however, is part of the routine evaluation of the suicidal patient.

Answer 99

B. amitriptyline

The answer is B. Antidepressant overdose is the most common cause of suicide by ingestion. Cyclic antidepressants are associated with a higher potential for lethality than other antidepressant medications. Often during the early stages of recovery from major depression, patients may have a "mobilization of energy" which allows them to act on their suicidal thoughts, for which they previously lacked the energy.

Answer 100

A. antibiotics for septic joint and admission for operation

The correct answer is A. The key to successful treatment of a septic joint is rapid diagnosis and treatment. Hospital admission for wash out of the joint and IV antibiotics are indicated for a septic joint. Antibiotics should be started based on gram stain or consideration of likely organisms and then adjusted based on final culture results.

Answer 101

B. drainage and discharge

The correct answer is B. This patient has a subungual hematoma. Large subungual hematomas require drainage using an 18-gauge needle or a hot microcautery unit. There is debate concerning management of a subungual hematoma greater than 50% of the nail bed. One study showed there was a 60% incidence of nail bed laceration in these patients; therefore, the authors recommended that the nail be removed and the laceration sutured. However, another study found no difference in outcome between nail trephination alone versus formal nail bed repair.

Answer 102

B. Referral to an otolaryngologist for foreign body removal under general anesthesia may be required in an uncooperative infant

The answer is B. Irrigating the ear canal with warm water is acceptable in many instances, and may remove a foreign object with minimal discomfort. Direct the water jet gently past the object, against the tympanic membrane, and then back out the ear canal, hopefully dislodging the foreign object in the process. However, this technique should not be used in cases of bean or seed insertion because such objects swell when moistened, which makes subsequent removal more difficult and increases the risk of pressure necrosis. Irrigation should also be avoided in cases of tympanic membrane perforation.
-- For further reading see Rosen’s Emergency Medicine: Concepts and Clinical
Practice, 5th edition, Chapter 53.
The answer is B. A, C, D, and E are all acceptable means of foreign body removal from the ear canal. Irrigating the ear canal with warm water is acceptable in many instances, and may remove a foreign object with minimal discomfort. Direct the water jet past the object, against the tympanic membrane, and then back out the ear canal, hopefully dislodging the foreign object in the process. However, this technique should not be used in cases of bean or seed insertion because such objects swell when moistened, which makes subsequent removal more difficult and increases the risk of pressure necrosis. Irrigation should also be avoided in cases of tympanic membrane perforation.

Answer 103

C. Radiography visualizes the nail in the gastric fundus

The answer is C. Observation can manage most ingested foreign objects – the patient should pass the object after several days. Propulsive agents can be given to speed movement along the gastrointestinal tract. Serial radiography monitors movement. Endoscopic or surgical intervention is indicated for sharp objects (which may cause perforation), objects greater than 2 cm in width (which are likely to lodge at the pylorus or the ileocecal valve), and long rigid objects (which may have trouble passing through the right angles of the duodenum). Surgery is indicated if an object fails to move after 24 hours (indicating impaction), or if the patient develops symptoms of obstruction or perforation.
Body packers may have ingested substances such as cocaine or heroin, which can cause great harm should the packaging be disrupted. Proper management is observation, as most will pass the package(s) without complications. Urgent package retrieval should not be performed because of pressures from law enforcement. Endoscopy can in fact be dangerous to the patient, as it can disrupt the packaging and release toxic drugs. Endoscopic or surgical intervention is warranted should the patient develop signs of systemic drug toxicity. The patient can also be monitored with serial serum drug levels.

Answer 104

A. incision and drainage with a linear incision

The answer is A. A fluctuant, indurated area such as that pictured and described, tends to not respond to antibiotics (which cannot penetrate well into the abscess cavity). Cruciate incisions are unnecessary and risk wound healing problems. A 30-gauge needle is too small, and needle drainage of an abscess in this location is not generally used (it is more likely appropriate in facial abscesses).

Answer 105

B. The needle entry angle that optimizes eversion of sutured skin edges.

The answer is B. Eversion of the skin edges is maximized by directing the needle entry as shown in the figure. Injection for local anesthesia should usually be performed through the wound, rather than through intact skin. Use of skin clamps can damage tissue; in cases where skin stabilization is needed gentle forceps application is preferred. Subcuticular sutures are placed deep to the skin.

Answer 106

C. a Bartholin’s cyst –– Word catheter

The answer is C. The patient’s Bartholin’s cyst will be drained, and placement of a Word catheter (inserted through an incision on the mucosal surface of the labia) will allow for continued drainage and healing.

Answer 107

B. Cormack-Lehane

The answer is B. The Cormack-Lehane scale allows communication of relative ease of visualization of laryngeal structures during laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway.

Answer 108

A. Ketamine

The answer is A. Ketamine is a dissociative anesthetic and relaxes bronchial smooth muscle, either by blocking parasympathetic effects or by increasing sympathomimetic stimulation. This relaxation can decrease airway resistance within minutes of administration. While the clinical relevance of ketamine's bronchodilation is subject to debate, most major texts mention it as an agent of choice for intubation of patients with reactive airways disease. All of the other induction agents mentioned do not cause bronchodilation.

Answer 109

D. May cause transient adrenal suppression and should be used with caution in septic patients

The answer is D. Etomidate has an acceptable side effect profile and is one of the primary induction agents in RSI. It is a sedative, reduces anxiety and is cardio-protective. Therefore it is primarily indicated for induction when decreased myocardial contractility is a concern. Patients allergic to soy or eggs should not receive propofol, but etomidate is safe to administer. Etomidate has been known to cause transient adrenal suppression and its use in septic patients is controversial.

Answer 110

D. lidocaine

The answer is D. Lidocaine and bupivacaine are amides but the latter is much more potent, intermediate in onset and longer lasting. Procaine and tetracaine are esters and both are slow in onset, but tetracaine is applied topically and has a potency comparable to bupivacaine. Procaine is the least potent of the listed anesthetics.

Answer 111

D. Spinal epidural hematoma

The answer is D. The back pain in this patient is likely secondary to a space-occupying lesion in the spinal canal. Epidural hematoma is the most likely option since it was sudden in onset, worse with coughing and occurred soon after the procedure. Adhesive arachnoiditis (A) would be manifest as a progressive loss of nerve function. Anterior spinal artery thrombus would be expected to present with painless paraplegia (B). A spinal epidural abscess would be unlikely so soon after the procedure and is more gradual in onset. The patient is not immunosuppressed and she does not have a fever, rigors or sweats which can be seen in up to 75% of patients.
--For further reading, see Rosen’s Emergency Medicine: Concepts and Clinical
Practices, 7th edition, pages 1391-2, 1396The back pain in this patient is likely secondary to a space-occupying lesion in the spinal canal. Epidural heoon after the procedure. Adhesive arachnoiditis (A) would be manifest as a progressive loss of nerve function. Anterior spinal artery thrombus would be expected to present with painless paraplegia (B). A spinal epidural abscess would be unlikely so soon after the procedure and is more gradual in onset. The patient is not immunosuppressed and she does not have a fever, rigors or sweats which can be seen in up to 75% of patients. --For further reading, see Rosen’s Emergency Medicine: Concepts and Clinical
Practices, 7th edition, pages 1391-2, 1396

Answer 112

C. The patient shown is undergoing a posterior tibial nerve block.

The answer is C. The nerve block depicted is a posterior tibial block. Regional blocks are preferred for procedures involving the plantar foot, since there is rich innervation and significant discomfort associated with injections into the soles. The posterior tibial nerve, located between the medial malleolus and Achilles tendon, supplies the medial portion of the sole and the medial side of the foot. The nerve runs next to the posterior tibial artery and is posterior to the pulse. In addition to the posterior tibial nerve block, a sural nerve block is frequently provided when anesthesia is desired for the heel and lateral foot.

Answer 113

C. Age < 5

The answer is C. Given that surgical cricothyrotomy is often resorted to only after other techniques have been unsuccessful and/or the patient is not oxygenating or ventilating, most authors state that the only absolute contraindication is age. Because of the anatomic differences between children versus adults including the smaller cricothyroid membrane and the rostral funnel shaped more compliant pediatric larynx, surgical cricothyrotomy has been contraindicated in infants and young children. However, the exact age at which a surgical cricothyrotomy can be done is controversial and not well defined. Various textbooks list the lower age limit from 5 years to 12 years. Choices A, C, and D are all relative contraindications to cricothyrotomy but may be overlooked in an emergent situation when the first priority is to obtain an airway.

Answer 114

D. lidocaine injection (lidocaine 2%) as digital nerve block anesthetic

The answer is D. In some cases surgical or dermatological consultants may utilize epinephrine-containing anesthetics in tissues with end-arterial blood supply. Although epinephrine-containing solutions are used routinely by podiatrists in digital blocks of the toes, without morbidity, when performing a digital block, it is advised to use anesthetics that do not contain epinephrine. If epinephrine-containing solutions are inadvertently used for a digital block in otherwise healthy individuals without peripheral vascular disease, it is unlikely that serious ischemic injury will occur. In the emergency department you should follow the general rule proscribing use of such agents in the digits, tip of the nose, penis, and pinna. The rationale for this prohibition is that vasoconstriction in these regions can result in ischemic complications, especially if the patient has underlying peripheral vascular disease. This patient was at risk. Standard concentrations of lidocaine are not likely to achieve effective analgesia when used topically.

Answer 115

C. If there is not much tension on the wound, a topical adhesive (such as Dermabond) may be used to approximate the wound edges

The answer is C. Eyebrow hair tends to not regrow after being shaved; a petroleum jelly can be used to “retract” the hair if necessary. If anesthesia is to be used to close this wound (wound glue would be a reasonable alternative), topical anesthesia is a good approach as long as care is taken to prevent drip into the eye. An infraorbital nerve block would not provide anesthesia to the area of the laceration. Epinephrine can be used safely in the supraorbital region.

Answer 116

B. “Undermining” subcutaneous tissues may be a useful technique to reduce post-closure skin tension.

The answer is B. Undermining of skin “recruits” tissue by separating the skin from the deeper subcutaneous structures. Though in some cases, slight excision of protruding fatty tissue may be necessary, trimming of all visible fatty tissue is unnecessary. The wound is subject to high tension, and thus 6-0 suture or tissue adhesives are not optimal choices for closure. Drains are rarely indicated for initial wound care in the ED, and would not be necessary in the wound in the Figure.

Answer 117

C. Lightheadedness and dizziness

The answer is C. Toxic reactions to local anesthetics are usually due to intramuscular or intrathecal injection, or to an excessive dose. The maximal acceptable dose of lidocaine with and without epinephrine is 7mg/kg and 5mg/kg respectively. The initial symptoms of local anesthetic toxicity are lightheadedness and dizziness. Other symptoms noted are peri-oral numbness, tinnitus, progressive CNS excitatory effects including visual and auditory disturbances, shivering, twitching, and, alternatively, generalized clonic-tonic seizures. CNS depression can follow leading to respiratory depression or arrest.

Answer 118

A. An ulnar nerve block would be a preferred method for wound anesthesia.

The answer is A. An ulnar nerve block provides anesthesia and is likely less painful than direct injection into the wound (which is another reasonable approach to wound anesthesia). Vertical mattress sutures are not recommended for the palm, as this technique places deep structures at risk. Topical skin adhesives are best avoided in the palm, which is prone to sweating and thus increasing the possibility of resultant wound dehiscence. Though many would recommend use of prophylactic antibiotics in a patient with a sufficiently deep palmar laceration, no controlled trials address use of antibiotics in patients with this – or just about any other – type of laceration.

Answer 119

C. Patient is younger than 3 years old and had a glass of milk four hours ago

The answer is C. Flumazenil should not be used on a patient exhibiting seizure activity (A). Also co-ingestion of drugs with pro-convulsant properties (cyclic antidepressants) is associated with an increased risk of seizures, presumably due to loss of the benzodiazepine’s protective anticonvulsant effect when the antagonist is
administered. For similar reasons (related to GABA effects) flumazenil can theoretically precipitate seizure activity in patients who chronically take benzodiazepines or chloral hydrate. The co-administration of flumazenil also risks cardiac side effects for these patients. Flumazenil would not be indicated for reversal of sedation when using only fentanyl or ketamine (B, D). Naloxone (or another opioid antagonist), not flumazenil, is the appropriate reversal agent for fentanyl. There is no reversal agent available for ketamine. Flumazenil can be used for the acute reversal of benzodiazapine overdose in procedural sedation for children younger than 3. The patient’s consumption of milk four hours earlier met the ASA fasting guidelines and is irrelevant.

Answer 120

A. Fentanyl

The answer is A. This patient is exhibiting clinical signs of chest wall rigidity and glottic spasm, which is a rare but classic side effect of using high doses of intravenous fentanyl. Chest wall rigidity and glottic spasm, which may make ventilation difficult, are unique complications seen with very high doses of fentanyl given rapidly (generally > 15 mcg/kg). It has been observed at lower doses. This may not reliably be antagonized by naloxone and may require neuromuscular blockade and intubation to enable adequate ventilation. This complication is very rarely reported with the dosages of fentanyl used for PSA but can still happen.

Answer 121

B. Mallampati

The answer is B. The Mallampati scale allows communication of ability to visualize structures of the posterior oropharynx, as a means of predicting ease of laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway.

Answer 122

C. Post LP headache is the most common complication of lumbar puncture

The answer is C. A smaller-diameter needle (not larger) is associated with a lower incidence of post-puncture headache because it causes a smaller dural hole (A). Simple analgesics are commonly prescribed, but they have no apparent advantage over bedrest and fluid intake. Lying supine for up to six hours carries no advantage over getting up after the procedure in the prevention of post spinal headache (B). Post LP headaches are typically bilateral and worse when sitting up (D). They improve with the supine position. Treatment of post-LP headache
commonly involves keeping the patient supine to maximize intracranial CSF volume, use of oral caffeine, and for severe long-lasting headaches, autologous blood patch. The blood patch involves injecting one’s own blood at the LP site in order to form a clot around the meningeal puncture site to avoid further leakage.

Answer 123

C. biopsy of a lung mass (anterior or posterior approach)

The answer is C. All the other answers are common indications for performing a thoracentesis. Lung biopsy is not performed in the emergency department.

Answer 124

E. Simple wound cleaning, bandaging, and tetanus immunization are appropriate therapy for this patient.

The answer is E. Tetanus can be probably be effective if administered within the first few days of a wound; 24 hours is not too late. Suturing of this wound is not indicated, since it is an old wound, well-approximated, and is on the flexor surface of the digit where skin forces will be minimal. Though suturing is not indicated, careful assessment of the finger for neurovascular injury is appropriate given the anatomical location of the wound over the bundle (the superficial appearance of the wound may be misleading).

Answer 125

D. 0.6:1

The answer is D. The normal range of CSF glucose is 50 to 80 mg/dL, which is 60% to 70% of the glucose concentration in the blood. Ventricular fluid glucose levels are 6 to 8 mg/dL higher than in lumbar fluid. A ratio of CSF glucose–to–blood glucose of less than 0.5 or a CSF glucose level below 40 mg/dL is invariably abnormal. The ratio is higher in infants, for whom a ratio of less than 0.6 is considered abnormal. Hyperglycemia may mask a depressed CSF glucose level; when present, the CSF glucose–to–blood glucose ratio should be measured routinely. With extreme hyperglycemia, a ratio of 0.3 is abnormal. In patients with systemic hyperglycemia, the ratio changes to 0.4:1.

Answer 126

C.. A chest x-ray is unnecessary before needle decompression

The answer is C. In an unstable patient such as this, a chest x-ray would delay the care of this patient and is unnecessary. This patient needs immediate intervention with needle decompression. A chest tube size of #28 French or greater would be indicated since this patient may have a hemothorax (B). Needle decompression involves placement of a #14 gauge needle in the 2nd intercostal space at the midclavicular line (C). The chest tube should be inserted over the upper border of the rib to avoid the neurovascular bundle at the inferior margin of each rib.

Answer 127

E. Digital block, a surgical intervention, and antibiotic therapy are all indicated in this patient

The answer is E. This patient has a paronychia, complicated by relatively significant extension of purulence as well as cellulitis in the involved great toe. In cases where the paronychia is small, simple lifting of the eponychium (cuticle) may suffice; no digital block is necessary. In a case such as this one, more aggressive intervention, including removal of part of the nail, will necessitate digital block. The patient does not require hospitalization, but antibiotics and close follow-up (especially if there are complicating issues such as diabetes) are indicated.

Answer 128

A. A nasogastric tube may be placed to facilitate treatment

The answer is A. Charcoal aspiration does carry with it the risk of developing a severe pneumonitis. If necessary, an uncooperative or combative patient may need to be intubated in order to safely deliver the charcoal with the airway secured. Suicidal patients do not have the right to refuse care, and physicians may do what they need to do in an effort to save the patient. In emergencies, parental permission for treatment is unnecessary.

Answer 129

B. Adult patient, nortriptyline ingestion (50 mg/tab x 100 tablets, 45 minutes PTA)

The answer is B. Gastric lavage (GL) is generally not effective if performed more than a few hours (exact time ranges depend on clinical circumstances) after ingestion. Due to risks of lavage (aspiration, gastric/esophageal perforation), trivial ingestions are not an indication for GL. Due to the risk of aspiration with hydrocarbons and further injury with caustic ingestions, GL is contraindicated for hydrocarbon and caustic ingestions

Answer 130

B. Cocaine

Cocaine is a sympathomimetic. Sympathomimetics and anticholinergics such as Jimson Weed can be differentiated by the presence of sweating although both can cause delirium and mydriasis. Aspirin or salicyclate toxicity can cause increased respiratory drive through direct stimulation of the medullary respiratory center but should not cause papillary changes. Heroin will result in a classic toxidrome of miosis, CNS and respiratory depression as will other opiates.

Answer 131

C. Flushed skin

The answer is C. The classic presentation of anticholinergic toxicity is best remembered by the following: hot as Hades; blind as a bat; dry as a bone; red as a beet; mad as a hatter. Patients with anticholinergic toxicity are flushed, warm, psychotic, mydriatic, and dry. Bowel sounds are classically hypoactive.

Answer 132

C. Ethanol

Answer 133

D. Acetaminophen overdose

Charcoal acts by adhering to most toxins, impairing toxin absorption,
and enhancing elimination. Some toxins (i.e., heavy metals such as lithium, lead, and
iron) do not bind to charcoal. Consequently, charcoal is not indicated in isolated heavy
metal injections. Also, charcoal is contraindicated in patients with unprotected airways
(risk of aspiration) and in caustic ingestions as the black color of the charcoal interferes
with the endoscopic evaluation that often follows caustic ingestion. In addition, a caustic ingestion such as alkaline drain cleaner causes its damage by direct contact rather than absorption so charcoal will not be effective.

Answer 134

B. Prolonged QRS interval

Answer 135

B. Prolonged QRS intervals

The answer is B. Tricyclic antidepressant (TCA) toxicity can result in the following EKG abnormalities: sinus tachycardia (through antimuscarinic activity), prolongation of any of the EKG intervals (through sodium and potassium channel blockade), ventricular dysrhythmias (sodium channel blockade), and right axis deviation of the terminal 40 ms of the QRS complex (sodium channel blockade).

Answer 136

C. Hemodialysis

The answer is C. Dehydration, over-diuresis, and drug-drug interaction (particularly NSAIDs) are common precipitants of lithium toxicity in the patient chronically taking lithium. In general, the clinical condition, not drug level, should guide therapy. In acute ingestions in particular, lithium levels do not correlate well with symptoms or prognosis. Charcoal does not bind heavy metals like lithium. Hemodialysis is helpful in lithium toxicity.

Answer 137

C. Intubation for airway support

The answer is C. Isolated benzodiazepine (BZD) OD is generally quite benign. When taken in combination with other agents, however, BZDs can cause significant morbidity and mortality. Patients with BZD OD commonly present with oversedation. A paradoxical excitation syndrome can occur but is uncommon. While an antidote (flumazenil) exists, supportive care is the key to treatment. Flumazenil, a BZD antagonist, can cause seizures in patients taking BZDs chronically by inducing an acute BZD withdrawal syndrome. It is best used in reversal of BZD-induced iatrogenic oversedation. Here, however, physicians must take heed as the half-life is short and resedation can occur.

Answer 138

D. Lorazepam

The answer is D. Benzodiazepines are the treatment mainstay for cocaine toxicity. Lorazepam and diazepam can be titrated to treat the symptoms of agitation and increased adrenergic tone common to patients with cocaine toxicity. Beta blockers
should not be administered due to a potential for unopposed alpha-adreneric
stimulation and resultant hypertension. Haloperidol and diphenhydramine can
contribute to the hyperthermia common to patients with cocaine toxicity.

Answer 139

A. Nystagmus

The answer is A. A patient with classic PCP intoxication presents with dramatic multidirectional nystagmus, hypertension, and bizarre behavior.

Answer 140

D. pH 7.45 pCO2 21 pO2 124 HCO3 14

The answer is D. Acute salicylate overdose characteristically causes a metabolic acidosis mixed with a respiratory alkalosis.
Reference

Answer 141

D. Activated charcoal is indicated to treat this ingestion

The answer is D. NAPQI -- the prime toxic mediator -- builds up when glutathione stores deplete and thus causes hepatotoxicity. The first stage of acetaminophen toxicity is largely asymptomatic. The toxic acetaminophen dose, when a single ingestion of nonsustained-release preparation is taken, is about 140 mg/kg. Therapy is guided by the Rumack-Matthew nomogram, provided the ingestion is an acute one involving nonsustained-release preparations. The antidote, N-acetylcysteine, prevents toxicity by inhibiting the binding of NAPQI to hepatocytes.

Answer 142

B. An acetaminophen level drawn at hour four dictates need for antidotal therapy.

The answer is B. An acetaminophen level drawn at hours 4-20 can be plotted on the Rumack-Matthew nomogram to guide therapy based on the potential for hepatic (not renal) toxicity. Liver function tests are not indicated for trivial acetaminophen ingestions, but may be useful in severe ingestions. Charcoal binds acetaminophen and should be given early. N-acetylcysteine (NAC), the antidote, is only FDA-approved in the United States for oral use, although IV NAC has been used safely for years in other countries. One side-effect of the IV preparation is anaphylactoid reaction.

Answer 143

D. Digoxin

The answer is D. Digoxin toxicity classically presents as weakness, fatigue,
nausea/vomiting/diarrhea, confusion, and a visual disturbance hallmarked by
yellow/green halos around objects.

Answer 144

A. Opioids

The answer is A. The hallmark signs and symptoms of clonidine toxicity include:hypotension, bradycardia, mental status change, respiratory depression, and miosis. The presentation very closely mimics opioid toxicity.

Answer 145

A. Amitriptyline

The answer is A. Amitriptyline is a tricyclic antidepressant (TCA). As such, it has anticholinergic activity that will cause a sinus tachycardia. Additional EKG findings with TCA toxicity include interval prolongation and terminal 40 ms right axis deviation. Clonidine, nifedipine, and metoprolol typically cause bradycardia. NSAIDs, like ibuprofen, rarely affect the heart rate.

Answer 146

C. Deferoxamine

The answer is C. Deferoxamine binds directly to free iron and thus is the antidote for iron toxicity. It is given intramuscularly or intravenously and often causes the patient’s urine to turn color (vin rosé urine). Methylene blue is an antidote for methemoglobinemia. N-acetylcysteine is the antidote for acetaminophen. Pyridoxine is the antidote for isoniazid toxicity and glucagon can serve as an antidote for beta blocker, calcium channel blocker, or insulin overdoses.

Answer 147

C. Endoscopy is useful in the assessment of injury

The answer is C. Gastric lavage and ipecac therapy are contraindicated due to concern regarding recurrent injury to the esophagus from a second contact with the caustic ingestant. Activated charcoal is contraindicated because it obscures endoscopic assessment (and doesn’t work at binding caustics). Neutralization with milk or water may be indicated in caustic ingestions without perforation, but strong acids/alkali should not be used. Endoscopic assessment should be performed early as the risk of procedurally-induced perforation increases with delayed endoscopy.

Answer 148

D. Memory loss

The answer is D. Lead toxicity affects a variety of systems. The central nervous system effects are many and range from encephalopathy and seizure to sleep disturbance and memory deficits. The peripheral nervous system can also be involved, with paresthesias and wrist drop being common. Colicky abdominal pain is often present. While dermatitis is not common in lead poisoning, you can see bluish lead lines on the gingiva.

Answer 149

B. Methylene blue

The answer is B. Nitrates/nitrites, local anesthetics, dapsone, and phenazopyridine are the common causes of methemoglobinemia. Methemoglobinemia causes the oxygen dissociation curve to shift to the left, making the remaining hemoglobin less likely to give up oxygen to the tissues. Blood from patients with methemoglobinemia is a chocolate brown color. Methylene blue is the antidote. Pulse oximetry is unreliable in patients with methemoglobinemia, since the pulse oximeter cannot differentiate oxyhemoglobin from methemoglobinemia.

Answer 150

Key is 30 minutes...

C. Respiratory alkalosis due to stimulation of the respiratory center and increased CO2 production

The answer is C. Aspirin, a salicylate, directly stimulates the medullary chemoreceptor trigger zone and respiratory center, leading to increased CO2 production and increased respiratory rate, causing a primary respiratory alkalosis. A primary metabolic acidosis typically develops as well. Salicylates are absorbed from the stomach and bowel wall and typically have onset of action within 30 minutes.

Answer 151

B. Tachypnea

The answer is B. Withdrawal syndromes tend to have symptoms that are the reverse of intoxication syndromes. In opiate withdrawal, individuals present with CNS excitation, diarrhea, mydriasis, tachypnea and often abdominal cramping and vomiting. While uncomfortable, opiate withdrawal is not life threatening and is managed symptomatically

Answer 152

C. Chest tube placement

The answer is C. This patient has a large right-sided spontaneous pneumothorax that is not under tension. She needs oxygen and chest tube placement. This can be done with proper procedural analgesia and sedation since there is no immediate threat. Primary spontaneous pneumothorax tends to occur in healthy young men (and, less commonly, women) of taller than average height. Other risk factors include cigarette smoking, asthma, COPD, interstitial lung disease, connective tissue diseases, and lung cancers.

Answer 153

A. Endotracheal tube adjustment

The answer is A. The patient has a right-mainstem intubation and resultant opacification of the left lung secondary to unilateral lack of ventilation. In an adult male, the ETT should generally be inserted to a depth (to the lip line) of 22-24cm; the corresponding depth range for an adult female is 21-23cm.

Answer 154

B. Bilateral pulmonary embolism

The answer is B. Helical CT studies of the pulmonary vasculature are increasingly used for detection of pulmonary embolism. Though there are questions about CT’s ability to detect small (e.g. subsegmental) emboli, CT scans have high sensitivity for proximal embolism such as that depicted in the accompanying figure. The patient whose images are shown was found to have moderate-severe right ventricular dysfunction and received thrombolytic therapy in the ED - she had an excellent outcome.

Answer 155

A. Mediastinal shift due to fluid in the right hemithorax

The answer is A. The patient is not intubated. The pathology in the right hemithorax appears as hyperdensity, rather than air density (not a pneumothorax), and involves more than the right upper lobe.

Answer 156

C. Prevalence increased in the 1980's, and then decreased in the 1990's

The answer is C. Despite an increase in asthma prevalence in the United States, Canada, Great Britain and Australia in the 1980s, the 1990s saw a decrease in prevalence in these areas. Regarding gender, male children are more likely than female children to have asthma, however the reverse is true with adults. African-Americans have a higher prevalence of asthma than Caucasians. Migrants who relocate from an area of low asthma prevalence to an area of high asthma prevalence tend to have an increased prevalence of asthma suggesting a role for environmental factors in the development of asthma.

Answer 157

C. The presence of pulsus paradoxis in asthma indicates severe disease

The answer is C. Pulsus paradoxus is defined as a fall in systolic blood pressure of greater than 10mm Hg upon inspiration. It is typically present during acute asthma exacerbations in severe asthma; however, its absence does not rule out severe disease. Although initially present, a pulsus paradoxus may disappear after only minimal improvement in air flow through the larger airways. Pulsus parodoxus may occur in other diseases besides asthma (for example, pericardial tamponade).

Answer 158

D. Inhaled steroids should be avoided

The answer is D. Oral and intravenous steroids are equally efficacious in treating an asthma exacerbation. Yet, in the setting of a severe asthma exacerbation, a patient may have difficulty taking oral medications and the intravenous route is preferred.

Answer 159

A. Anticholinergics by inhalation may be beneficial

The answer is A. Salmeterol is a long-acting beta2-selective adrenergic agonist that has no role in the treatment of an acute asthma exacerbation, but it is frequently preferred for outpatient asthma management due to its BID dosing schedule.

Answer 160

A. Beta adrenergic agonists such as albuterol

The answer is A. Mucokinetic agents should not be used acutely in treatment of COPD exacerbation. These agents act to mobilize secretions, and this increases the work of the patient’s breathing.

Answer 161

A. Co-infection with multiple bacteria, such as Chlamydia and Strep pneumoniae commonly occur

The answer is A. Co-infection with multiple bacteria, such as Chlamydia and S. pneumoniae, is a well-recognized occurrence and should be sought out to ensure appropriate antibiotic coverage.

Answer 162

D. lidocaine

OUTDATED

The answer is D. Ventricular fibrillation is primarily treated with defibrillation. If three successive shocks and epinephrine have been given, the next line agent would be an antiarrhythmic, such as lidocaine or amiodarone.

Answer 163

E. magnesium sulfate

The answer is E. Torsades de pointes is a form of ventricular tachycardia in which the QRS morphology twists around the baseline. It may occur spontaneously in the setting of hypokalemia, hypomagnesia, or any drug that prolongs the QT interval. Magnesium best controls it. If that fails, try overdrive pacing. The unstable patient should be cardioverted when the rhythm is sustained, but cardioversion is not likely to have sustained success in the absence of adjunctive therapy (e.g. magnesium).

Answer 164

C. Identification and treatment of a reversible underlying etiology

The answer is C. “Patients with PEA and asystole have poor outcomes, but the identification of the underlying etiology is extremely important and the common causes should be reviewed, treated, or excluded during the resuscitation.”

Answer 165

E. immediate defibrillation up to three times

The answer is E. Unstable VT is treated by a series of three stacked shocks, before medications. Early defibrillation is the key to successful resuscitation.

Answer 166

D. Two to three times the standard dose should be used

The answer is D. Several medications can be given via the endotracheal (ET) tube as well, if IV or IO access has not been established. The optimal dosing of drugs administered endotracheally has not been established, but 2-2 1/2 times the IV route is generally accepted.

Answer 167

C. 1mg of 1:10,000

The answer is C. “Epinephrine remains the adrenergic drug of choice in the ACLS guidelines. The 2005 ACLS guidelines recommended the administration of 1 milligram IV or IO of a 1:10,000 solution every 3 to 5 minutes. Doses >1 milligram are not recommended and may be harmful.”

Answer 168

D. epinephrine

The answer is D. The flat line above is characteristic of asystole. This is mechanical
and electrical standstill. It is important to check that the monitor is working and to check
a second lead to rule out very fine ventricular fibrillation. The treatment of choice is
epinephrine or vasopressin and atropine

Answer 169

C. ventricular fibrillation

The answer is C. Ventricular fibrillation is the totally disorganized depolarization and contraction of the ventricles. The EKG is characterized by a variable zig-zag pattern of very rapid, chaotic, and grossly irregular deflections of irregular appearance and varying amplitude. There are no discernible P waves, ST segments, T waves, or even QRS complexes.

Answer 170

B. complete heart block

The answer is B. In complete AV block, there is no relationship between the P waves (atrial beats) and the ventricular beats. The latter arises from different foci, thus the QRS complex is wide (impulse is not conducted through the normal pathways) and the rate is often slow at < 50/minutes. Complete heart block is common in the setting of ischemia and also in the peri-infarct period. The treatment for complete AV block in this setting is usually permanent pacing.

Answer 171

E. The chin-lift maneuver risks spinal injury due to its employment of neck extension.

The answer is E. In many patients in the Emergency Department, the inability to rule-out cervical spine injury negates the option to use the chin-lift maneuver, since this method of airway opening can exacerbate C-spine injury.

Answer 172

A. Serum bicarbonate is typically severely low (<10mEq) in patients with either DKA or HHNC.

The answer is A. Although patients with DKA typically have profound metabolic acidosis with serum bicarbonate < 10mEq, acidosis is typically absent in patients with HHNC and serum bicarbonate is usually > 15 mEq.

Answer 173

A. A normal magnesium level is reassuring and obviates the need for magnesium replacement.

The answer is A. Patients with DKA are typically severely dehydrated with a total body water deficit of approximately 70-80 mL/kg, in addition to being total body depleted of potassium, magnesium, and phosphorous despite initially normal serum levels of these electrolytes.

Answer 174

E. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.

The answer is E. Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity.

Answer 175

A. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema.

The answer is A. Steroids are not indicated for treatment of cerebral edema and may actually worsen DKA. Mannitol 0.25-2.0 mg/kg should be administered upon any change in mental status of children being treated for DKA as they are at high risk for developing cerebral edema especially when being treated with insulin and serum glucose is below 250 mg/dL.

Answer 176

E. calcium

The answer is E. Hyperkalemia with EKG changes is treated with calcium to stabilize cardiac membranes. Calcium works quickly and is relatively safe unless patients are digitalized. Other treatments for acute hyperkalemia include sodium bicarbonate and insulin/glucose.

Answer 177

B. Calcium

The answer is B. “Immediate antagonism of K+ at the cardiac membrane is achieved with IV administration of calcium chloride or gluconate. This is indicated in patients with unstable dysrhythmia or hypotension.”

Answer 178

C. hyperkalemia

The answer is C. The EKG shows signs of hyperkalemia as characterized by diffuse peaked T waves. Other EKG changes include widening of the QRS complex and biphasic QRS-T segments. The heart rate may be slow, with ventricular fibrillation and cardiac arrest as the terminal events. Acute myocardial ischemia can be represented by hyperacute T waves as well, but in these cases the T wave changes are more likely to be focal (i.e. in an anatomical distribution corresponding to the area of threatened myocardium).

Answer 179

D. Hypoglycemia can present with virtually any neurological deficit.

The answer is D. Glucagon is ineffective in patients without adequate glycogen stores, as would be expected in alcoholics. Further, glucagon can precipitate a severe lactic acidosis in patients with glycogen storage diseases and therefore should not be used in children with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include sweating, tachycardia, nervousness, hunger, and neurologic symptoms. Symptoms should not be attributed to hypoglycemia unless the level falls below 40-50 mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by skipping a meal, or by increasing energy output or insulin dose. Due to the extended half-lives of the oral hypoglycemic agents, hospitalization and 24-hour observation (at minimum) are the typical management for overdose of these agents.

Answer 180

C. Altered mental status

The answer is C. Moderate hypothermia is associated with temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea

Answer 181

C. Immersion in warm water bath

The answer is C. Immersion of the affected extremity is the mainstay of treatment for patients with frostbite. Numbness of the affected area is the most common initial symptom and severe pain is frequently encountered after rewarming. Tetanus prophylaxis and debridement is indicated , but is not the most appropriate initial step in the management of patients with frostbite.

Answer 182

A. Hypothyroidism does not occur in infants under six months of age.

The answer is A. Hypothyroidism may occur at any age including the very young, but is infrequently seen in infants due to regular newborn screening for hypothyroidism. The increased frequency of the disease in women is attributed to the increased prevalence of autoimmune thyroid conditions in women. The majority of cases present in winter months due to the body’s decreased ability to accommodate to cold weather in a hypothyroid state.

Answer 183

E. Free thyroxine (T4) is always depressed in hypothyroid states.

The answer is E. Free T4 may be normal in early stages of hypothyroidism due to physiologic compensation from elevated TSH levels.

Answer 184

A. hyperglycemia

The answer is A. Hyperglycemia is not typically associated with hypothyroidism. Hypoglycemia may be present, but is unusual, and may suggest hypothalamic-pituitary involvement. Hyponatremia is common and corrects with thyroid replacement. Hypercholesterolemia to over 250 mg/dL is typical. A mild normochromic, normocytic anemia may be present, in addition to respiratory acidosis from hypoventilation.

Answer 185

C. hypokalemia

The answer is C. Hyperkalemia is seen in approximately 64% of patients with adrenal failure. Typically this is because of aldosterone production failure that normally enhances potassium excretion. Even more common is hyponatremia, present in 88% of patients. Hypoglycemia is present in two-thirds of patients and is a significant cause of morbidity and mortality associated with adrenal failure. Hypercalcemia is seen in 6 to 33% for unclear reasons; azotemia and increased hematocrit from hypovolemia may also be present.

Answer 186

D. dexamthasone 4mg IV every 6 hours

The answer is D. Dexamthasone is the treatment of choice in suspected but not confirmed adrenal insufficiency. It will not affect the serum cortisol level; therefore, it will not interfere with the diagnosis of adrenal insufficiency using the ACTH stimulation test. Administering cosyntropin, a synthetic form of ACTH, and measuring the serum cortisol levels typically perform the ACTH stimulation test. In confirmed adrenal insufficiency, hydrocortisone IV or cortisone IM are the treatments of choice.

Answer 187

E. hyperpigmentation

The answer is E. Hyperpigmentation is seen in greater than 90% of primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion. The secretion is a feedback mechanism that is not activated in secondary adrenal insufficiency, for example, adrenal insufficiency from pituitary infarction or hypothalamic insufficiency.

Answer 188

B. pregnancy

The answer is B. Untreated pneumothorax is an absolute contraindication to HBO therapy. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy. The COPD patient with a large bleb represents a relative contraindication for similar reasons. Treatment with doxorubicin, and many other drugs -- such as cisplatin (Cisplatinum®), bleomycin (Blenoxane®), disulfiram (Antabuse®), and mafenide acetate (Sulfamylon®) -- contraindicates HBO therapy because of potentially toxic effects when combined with HBO. URI illnesses such as otitis media are relative contraindications, due to the potential for tympanic membrane rupture secondary to inability of the ears to equalize pressure during therapy. This can be addressed through myringotomy with placement of tubes (in cases where multiple HBO treatments are anticipated). In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and “doses” (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed pregnant patients. This is due to the high affinity of fetal hemoglobin for CO.

Answer 189

A. necrotizing enterocolitis

The answer is A. According to the Undersea and Hyperbaric Medical Society, items A-D are all reasonable indications for the use of hyperbaric oxygen therapy. Other potential indications include patients with air or gas embolism, crush injury, and compartment syndrome.

Answer 190

C. Ascend with the rest of the team.

The answer is C. The syndrome of high altitude illness ranges from mild AMS (Acute Mountain Sickness) to life threatening conditions of HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). This student is experiencing mild AMS. After the symptoms of altitude illness occur, further ascent to a higher sleeping altitude is contraindicated. Halting ascent or activity to allow further acclimatization may reverse symptoms. Acetazolamide is a carbonic anhhydrase inhibitor that induces a renal bicarbonate diuresis, causing a metabolic acidosis and thereby increasing ventilation and arterial oxygenation. Supplemental oxygen addresses the hypoxic insult of high altitude exposure. Ibuprofen is useful for the treatment of his headache. Dexamethasone can help with the symptoms of AMS, but does not play a role in acclimatization.

Answer 191

B. Hyperthyroidism

The answer is B. Atrial fibrillation is a common arrhythmia. Its hallmark is the absence of P waves and irregular rhythm. It is associated with many medical conditions including ischemic heart disease and thyrotoxicosis. Atrial fibrillation increases the risk of thrombus formation and arterial embolism. AF’s many treatment options include calcium channel blockers, beta blockers, amiodarone, quinidine, and cardioversion. Pacing is not a treatment option.

Answer 192

A. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease.

The answer is A. The diagnosis of thyroid storm in the emergency department may be challenging due to the relatively infrequent occurrence of the disease and its typically nonspecific signs and symptoms. Treatment should be initiated in a timely fashion in any patient suspected of having thyroid storm due to the potential lethality of this disease. Immediate laboratory testing is typically not available to confirm clinically suspected cases, although thyroxine (T4) radioimmunoassay and free T4 index are good screening tests for hyperthyroidism. Clinical presentation of thyroid storm may be mistaken for psychiatric illness, heat stroke, sympathomimetic toxidromes, hypoglycemia and withdrawal syndromes, among others. Altered mental status, though frequently present, is not a prerequisite for diagnosis.

Answer 193

E. hypothermia

The answer is E. Fever, not hypothermia, is commonly seen in thyrotoxicosis. Other common signs and symptoms include tachycardia, congestive heart failure, wide pulse pressure, tremor, thyrotoxic stare, thyromegaly, nervousness, weight loss, and palpitations.

Answer 194

A. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given.

The answer is A. Iodine inhibits preformed thyroid hormone release and should be administered at least one hour after treatment with PTU to prevent organification of iodine. A typical dose is potassium iodide (SSKI) 5 drops every 6 hours PO or NG, or sodium iodide 1 gm slow IV drip every 8 to 12 hours. Iodine should not be administered to patients with known iodine allergy.

Answer 195

D. amiodarone to control dysrhythmias

The answer is D. Amiodarone is an iodine-rich antidysrhythmic with poorly-defined effects on thyroid function that has been associated with both hyperthyroidism and hypothyroidism. It should therefore be avoided in the management of thyroid disease. Propranolol is standard therapy in thyroid storm and, in addition to its effects of adrenergic blockade, also may reduce dysrhythmias. Of note, aspirin should be avoided in the treatment of hyperpyrexia as it may increase the level of active thyroid hormone by displacing thyroid hormone from thyroglobulin.

Answer 196

A. Complications of treatment with antivenom include delayed serum sickness

The answer is A. Most scorpion envenomations are mild, limited to pain and paresthesias at the site of envenomation. Children are affected more severely than adults: restlessness, jerking movements of the limbs, roving eye movements, and drooling are seen in severe cases. Anaphylaxis can also occur. Intubation is required rarely. Most envenomations require analgesics only; antivenom is indicated for severe reactions and anaphylaxis. Antivenom treatment is not without complications – serum sickness, and immediate and delayed hypersensitivity reactions occur. Without antivenom treatment, symptoms usually last for 1-2 days

Answer 197

A. Pain and paresthesias

The answer is A. Although there are many toxic species of scorpions in the world, and all can sting humans, only a few cause serious toxicity. In the United States, only Centruroides exilicauda is capable of causing systemic toxicity. The sting is followed immediately by localized pain and paresthesias, and these can progress to involve the entire extremity or body. Systemic symptoms are unusual in adults, but more common and severe in children. Evidence of a sting, such as a puncture wound is almost never seen on exam. The mainstay of treatment is analgesia. Although antivenom is very effective in alleviating symptoms, both immediate and delayed allergic reactions occur with its use. Routine use of antivenom is not indicated, as most symptoms usually resolve in 1-2 days.

Answer 198

D. Discharge home in 8 hours if patient’s exam remains unchanged

The answer is D. The patient is unlikely to suffer envenomation if he does not have any local or systemic symptoms in 8 hours. The dosage of antivenom is dependent on the degree of symptoms and children receive a proportionately higher dose compared to adults. Prophylactic antibiotics are not recommended

Answer 199

A. Heat stroke

The answer is A. Heat stroke is a life-threatening illness defined clinically as a core body temperature that rises above 40.5 degrees Celsius and is usually accompanied by hot, dry skin (though in some cases sweating may be present) and central nervous system abnormalities such as delirium, convulsions, and coma. Treatment goals include lowering the core temperature to < 39.4 degrees Celsius by promoting cooling through conduction and evaporation and treating the complications that might arise with heat stroke, including seizures, respiratory failure, hypotension, rhabdomyolysis, and multi-organ dysfunction syndrome. Acute anticholinergic toxicity may sometimes present with a picture like that of heat stroke, and although the answer options C, D, and E may lead to confused behavior and/or fever in an elderly individual, the constellation of symptoms seen in this woman is most suggestive of heat stroke.

Answer 200

C. Administer warm IV fluids

The answer is C. The patient is suffering from severe hypothermia. Atrial dysrhythmias are common below 32o C and are associated with a slow ventricular response. It usually converts spontaneously with rewarming. While answers B through E are all active rewarming techniques (active external – Bair Hugger, AVA rewarming, immersion, active core – peritoneal lavage), the best answer for someone with severe hypothermia with mental status change and cardiac dysrhythmias is probably active core rewarming . This technique minimizes rewarming collapse in patients with temperatures below 32o C. The patient will likely need intubated as ileus, bronchorrhea, and depressed protective airway reflexes are common with hypothermia.

Answer 201

B. extensive skin burns

The answer is B. A lightning strike is the discharge of a massive amount of current over a very short period of time. This often causes “short-circuiting” of electrical systems such as heart, respiratory centers, and central and autonomic nervous systems, in addition to arterial and muscular spasm. However, significant skin burns and deep tissue destruction seldom occur.

Answer 202

B. A false positive may be caused by the presence of methylene blue

The answer is B. Red fruits or meats, methylene blue, chlorophyll, iodide, cupric sulfate and bromide preparations can cause a false positive guaiac test. A false negative guaiac test can be caused by bile or ingestion of magnesium-containing antacids or ascorbic acid. Red Jell-O, tomato sauce, wine, iron therapy and Pepto-Bismol may cause the stool to look bloody when it is not.

Answer 203

C. colonoscopy to rule out inflammatory bowel disease

The answer is C. This patient will need a colonoscopy with intestinal biopsy to evaluate for inflammatory bowel disease such as ulcerative colitis and Crohn’s disease or other causes of colitis. Appendicitis usually presents with periumbilical pain migrating to the right lower quadrant with associated anorexia, not bloody bowel movements. Intussusception is uncommon after the age of 6. A stool culture should be obtained to rule out bacterial colitis, but his history is less suggestive of this.

Answer 204

C. Ischemic colitis

The answer is C. Thumbprinting represents local areas of swelling in the bowel mucosa caused by submucosal edema and hemorrhage and suggests ischemic colitis.

Answer 205

D. Diverticulosis

The answer is D. Diverticulosis and angiodysplasia account for 80% of lower GI bleeds. In approximately 10% of all patients with GI bleeding, no source of bleeding will be found.

Answer 206

D. Peptic ulcer disease (PUD)

The answer is D. The most common causes of upper GI bleeding are (in descending order of frequency): PUD, gastric erosions, varices, Mallory-Weiss tears, esophagitis, and duodenitis.

Answer 207

D. The majority of bleeding from diverticula occurs from the right side of the colon

The answer is D. There are many specific etiologies that cause gastrointestinal bleeding. In general, however, the mortality of upper gastrointestinal bleeding is higher than lower gastrointestinal bleeding. In adults, the most common cause of upper gastrointestinal bleeding is peptic ulcer disease. In children, it is esophagitis. Unfortunately, it can be difficult to diagnose the source of gastrointestinal bleeding as the bleeding may often stop and start spontaneously or from different sites.

Answer 208

A. Place two intravenous lines that are 22-gauge.

The answer is A. The patient is having gastrointestinal bleeding most likely from a peptic ulcer given his history. Urgent first steps in management include placement of two intravenous lines that are larger-bore than 22-gauge (18 gauge or larger size preferred) to enable rapid volume resuscitation, in addition to the oxygen, monitoring, intravenous fluids and preparation of blood products. Patients with an upper GI bleed who remain hemodynamically unstable require urgent consultation with gastroenterology.

Answer 209

B. Diverticulosis

The answer is B. Diverticulosis is the most common cause of lower GI bleeding. Angiodysplasia is the more common in young people. For further reading, please see Marx JA.

Answer 210

D. An anal fissure

The answer is D. Sudden sharp pain after defecation along with blood on toilet tissue characterizes anal fissures. A thrombosed external hemorrhoid causes painful bleeding on defecation. Usually there is a history of external hemorrhoids and associated itching, swelling, and mucoid drainage. Internal hemorrhoids usually exhibit painless bleeding that may drip into the toilet after defecation. Rectal cancers also have painless bleeding but usually are associated with a change in bowel movement character and other signs and symptoms of malignancy.

Answer 211

C. Clostridium perfringens

The answer is C. Clostridium perfringens is the most common cause of food poisoning in the United States. Patients ingest heat-resistant spores of C. pergringens which produce an enterotoxin in the GI tract. Campylobacter, E. coli 0157, Salmonella and Yersinia are all invasive bacteria that can cause bloody enteritis.

Answer 212

B. inferior myocardial infarction

The answer is B. The EKG demonstrates classic findings (ST-segment elevations in II, III, AVF) associated with inferior myocardial infarction.

Answer 213

E. Call cardiology for a decision between thrombolytic and percutaneous coronary intervention.

The answer is E. This patient is having an acute myocardial infarction. AMI is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered – selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection.
-- For further reading, see Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 1011-1052; 170.

Answer 214

C. ST-segment elevation of at least 1 mm in two or more contiguous leads

The answer is C. “Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-segment elevation in two or more contiguous leads.”

Answer 215

A. EKG with right-sided leads

The answer is A. “Nitrate-induced hypotension is also suggestive of right ventricular infarction, and of tamponade. Initial therapy for both would include volume loading and avoidance of vasodilators or other agents that may lower the blood pressure.”

“ST segment elevation in lead V1 in the setting of inferior MI (i.e., ST segment elevation in leads II, III, and aVF rather than in the setting of concomitant ST segment elevation in all anterior precordial leads) is suggestive of right ventricular infarction.”

“ST segment elevation is usually greater in lead III than in lead II when right ventricular infarction coexists with inferior AMI.”

“Application of “right-sided” precordial leads is the best means to diagnose right ventricular infarction with the ECG. These leads, as a mirror image of the left precordial leads, demonstrate ST segment elevation with right ventricular infarction in leads V3R to V6R, with V4R having the highest sensitivity.”

Answer 216

C. right-ventricular MI

The answer is C. The ST-segment elevation in the right-sided lead V4R is strongly suggestive of right-ventricular MI.

Answer 217

A. Urgent placement of a cardiac pacemaker

The answer is A. “In the face of an AMI, the risks of complete heart block are much greater when new or preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic placement of a ventricular demand pacemaker is indicated.”

Answer 218

A. left anterior descending (LAD)

The answer is A. This EKG pattern is consistent with that of anterior wall myocardial infarction (MI). The LAD supplies the anterior wall of the myocardium. The left circumflex artery, the LAD, or a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion of a branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF and I, aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in leads II, III and aVF causes an inferior MI. The right ventricle is usually supplied by the RCA or, less commonly, a dominant left circumflex. ST elevation in leads V4 and V5 of a right-side leads EKG suggests infarction of the right ventricle. A posterior MI (ST depression in V1-V3) results from occlusion of the RCA, its posterior descending branch, or a dominant left circumflex.

Answer 219

C. CT of the chest with IV contrast

“CT of the chest is the test most often used to confirm the diagnosis of aortic dissection. CT is readily available in most Emergency Departments, and has a sensitivity of 83-98% and specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits associated with the use of CT include the ability to identify intramural thrombus, pericardial effusion, and potentially reveal another etiology for the patient's pain. The major disadvantage of CT is the need for iodinated contrast, which requires normal renal function.”

Answer 220

A. Start IV beta blocker to decrease shearing forces on the aorta and IV sodium nitroprusside to lower blood pressure.

The answer is A. When a patient has an aortic dissection, it is important to decrease further dissection (i.e. extension of the vascular tear) by reducing shearing forces on the aorta using negative inotropes (beta blockers) and to control hypertension. Sodium nitroprusside is often used for blood pressure control in dissections as it is an easily titratable antihypertensive. Because sodium nitroprusside increases heart rate and may increase shearing forces, a beta blocker should be started before (or concurrently with) it. The effects of nitroglycerin are not easily titratable, making it a less desirable drug for blood pressure control. Aspirin should be avoided, as it may increase bleeding complications. Morphine may be used for pain control and to decrease sympathetic tone. Imaging decisions surrounding aortic dissection are complex, incorporating such factors as patient safety (e.g. transport to imaging areas, administration of dye loads) and need for assessment of nonaortic structures (e.g. pericardial space) and functional anatomy (e.g. valvular regurgitation). As a general rule, MRI is not emergently available and lacks sufficient monitoring capabilities for a patient with suspected acute aortic dissection (MRI is useful for long-term, outpatient monitoring of dissection in most centers).

Answer 221

D. stable angina

The answer is D. Acute coronary syndrome is a spectrum of myocardial ischemia through myocardial necrosis. The spectrum includes unstable angina, stable angina and acute myocardial infarction. Unstable angina is of new or recent onset, of changing character, or angina at rest. Stable angina or angina pectoris is chronic and episodic, usually lasting 5 to 15 minutes and relieved by rest or nitroglycerin. Variant angina usually occurs at rest, often precipitated by tobacco or cocaine use. It is defined as ST elevation that resolves as pain goes away. It is thought to be due to artery spasm.

Answer 222

A. Dressler’s syndrome

The answer is A. Dressler’s syndrome is fever, pleuritis, leukocytosis, pericardial friction rub, and evidence of pericarditis or pleural effusion occurring several weeks after MI. It is thought to be autoimmune in nature and is treated with NSAIDs.

Answer 223

B. ventricular tachycardia

The answer is B. Ventricular tachycardia is wide and complex. It is distinguished from supraventricular tachycardia by width and morphology of the QRS complexes. (Though there are numerous exceptions, supraventricular tachycardias usually exhibit narrow QRS complexes with morphology similar to that when the patient is in sinus rhythm.)

Answer 224

B. complete heart block

Answer 225

D. right-ventricular myocardial ischemia

The answer is D. The EKG’s marked ST-segment elevation in V1, in the absence of ST-segment elevation in the other anteroseptal leads (V2-V3), is suggestive of right-ventricular ischemia. Right-sided leads should be performed to further assess this possibility.

Answer 226

A. aortic dissection - nitroprusside/propranolol

The answer is A. The specific utilization of various medications for the
above-mentioned disease processes is subject to debate. For example, aortic
dissection therapy generally includes nitroprusside and a beta-blocker, and labetalol is considered a reasonable drug of first choice for many hypertensive conditions. However, captopril is not safe in patients with renal artery stenosis. The problem with using captopril in these patients is that its mechanism of action incurs risk of renal failure in patients with some types of chronic renal disease including renal artery stenosis. Patients with pregnancy induced hypertension have a decreased intravascular volume, despite the edema, and pheochromocytoma is treated with phentolamine.

Answer 227

A. hypertensive crisis

The answer is A. Elevated blood pressure in the setting of optic disk edema is a hallmark of malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While hypertensive urgency is not consistently defined in the medical literature, this patient's presentation indicates that there is some end-organ damage and thus the diagnosis is malignant hypertension. The "white-coat" syndrome, in which patients' blood pressures are elevated only in the clinical setting and not at home, has been shown to account for as many as a fifth of all cases of newly diagnosed "hypertension." Understanding of this phenomenom is important for emergency physicians, since its frequency explains why patients should not be given a diagnosis of new-onset hypertension based on E.D. measurements.

Answer 228

B. Lorazepam

The answer is B. The correct answer is A. In a patient with suspected myocardial ischemia secondary to cocaine abuse, beta blockade (choices B and D) is probably contraindicated as it may lead to uncontrolled alpha-agonism and could cause worsening hypertension (this notion continues to be debated). Lidocaine is contraindicated and the use of nitroglycerin is controversial.

Answer 229

D. Pneumomediastinum

The answer is D. Look closely along the right heart border and mediastinum. There is a thin strip of air. Pneumomediastinum and pneumopericardium result from Valsalva maneuvers, barotrauma, asthma, and cocaine inhalation from positive pressure devices. On physical exam there may be a Hamman’s sign or mediastinal crunch heard over the precordium. Westermark’s sign is dilation of pulmonary vessels proximal to a pulmonary embolism resulting in a cut-off appearance of the vessel on CXR.

Answer 230

A. Cocaine

The answer is A. Cocaine toxicity can cause a variety of cardiovascular sequelae including: cardiac dysrhythmias, coronary artery vasospasm, myocardial
ischemia/infarction, and aortic dissection. The central nervous system is also
commonly involved with seizures, intracranial hemorrhages/infarctions and
hypertensive encephalopathy being common. Mesenteric ischemia can occur as well
as rhabdomyolysis.

Answer 231

C. Chest CT scan

The answer is C. This patient most likely has a PE and has a sufficient presentation to warrant immediate anticoagulation therapy with heparin unless contraindications are present. Risk factors for PE include history of deep venous thrombosis (DVT), recent surgery or pregnancy, limb immobilization, confinement to bed, or underlying malignancy. Other risk factors include HTN, obesity, estrogen replacement therapy or oral contraceptives, autoimmune diseases, and cancer. Symptoms of PE include: dyspnea, pleuritic chest pain, apprehension, cough, hemoptysis, sweating, and syncope. The diagnosis is made: (1) if DVT is demonstrated by duplex US, venography, CT, MRI or some other technique; (2) if V/Q scan is convincingly positive; or (3) if pulmonary angiography, spiral CT, or another convincing test is positive.

Answer 232

D. thrombotic

The answer is D. TIAs are associated with increased risk for thrombotic strokes, the result of ulceration of cerebral artery plaque. Patients with TIA have a 5 to 6% percent chance per year of having a stroke. Antiplatelet therapy reduces risk of stroke in these patients.

Answer 233

D. hypernatremia

Answer 234

A. Perform a lumbar puncture to rule out the possibility of subarachnoid hemorrhage.

The answer is A. Sudden onset headache with nausea, vomiting, photophobia, or neck stiffness should raise the concern for spontaneous subarachnoid hemorrhage. Sensitivity of a non-contrast CT scan varies with respect to many factors (e.g. time since bleed) but is generally in the range of 90%; therefore, if the clinical suspicion is high, a lumbar puncture should be performed and a cell count for red blood cells done.

Answer 235

A. Most often a result of a skull fracture that traverses a venous sinus

The answer is A. Epidural hemorrhage is most often associated with skull fracture across the course of the middle meningeal artery.

Answer 236

D. Children less than 2 years

The answer is D. Epidural hematoma (EDH) is less likely in children and elderly because of the close attachment of the dura to the periostium of the skull. This is especially true of children less than 2 years because of the added elasticity of the skull.

Answer 237

D. Hemotympanum

The answer is D. Although hemotympanum may be found in a patient with an epidural hematoma, it is specifically associated with basilar skull fracture.

Answer 238

A. HSV encephalitis

Answer 239

E. All of the above

Answer 240

B. Patients should be told to keep their neck in maximal flexion throughout the procedure.

Answer 241

B. lacunar

The answer is B. Lacunar infarcts occur at the small, terminal branches of the vasculature and more commonly occur in African-Americans and patients with diabetes and hypertension. This patient’s presentation, evidenced by pure loss of motor function without disturbances in other neurological modalities, is consistent with an infarct in the internal capsule. Because terminal branches of the vasculature supply the internal capsule, it is frequently affected in patients with diabetes and hypertension. A vascular obstruction in the MCA would affect not only motor functions, but also produce cortical findings such as aphasia or agnosia.

Answer 242

D. ceftriaxone IV

The answer is D. In patients with meningitis, early antibiotics administration is of the utmost importance. Antibiotic administration should not be delayed to await diagnostic work up. Ceftriaxone, administered in some regions with vancomycin depending on the resistance profile of likely etiologic agents, is generally considered an antibiotic of choice in meningitis. Azithromycin and levofloxacin do not have good CNS penetration and therefore are not indicated for meningitis.

Answer 243

B. CT of the brain with and without intravenous contrast.

The answer is B. Bell’s palsy is an idiopathic palsy of the facial nerve. Although it is the most common cause of a facial nerve palsy, other etiologies must be ruled out. Inability to move the forehead muscle indicates a peripheral lesion, making stroke much less likely. If the remainder of the neurological exam is normal, then imaging is not needed. Lyme disease is a well known cause of facial nerve palsy and patients should be evaluated for this if they live in an endemic region. Half of cases present with retroauricular pain around the time of onset. Most neurologists recommend a short course of prednisone as part of treatment. There is evidence that herpes simplex virus is involved as a causative agent, and acyclovir is recommended. Also extremely important is to protect the involved eye, as it is at risk of drying out because lacrimal gland functioning can be impaired, and the eye is unable to close fully.

Answer 244

E. labyrinthitis

The answer is E. Determination of hearing loss is important in the evaluation of vertigo. Central vertigo, such as that which may be associated with multiple sclerosis or stroke, is not accompanied by acute hearing loss because of the distributed nature of the CN VIII nuclei. Acoustic neuroma, a central process, can cause hearing loss because of direct compression of the CN VIII. Even though vestibular neuronitis involves inflammation of CN VIII, it is not associated with hearing loss. Benign positional vertigo is caused by loose particles in the semicircular canals that induce a false sense of motion; however, auditory hearing is unaffected. Labyrinthitis, or inflammation of inner ear structures including semicircular canals and cochlea, can result in sensorineural hearing loss.

Answer 245

D. Diplopia

The answer is D. Any cranial nerve deficit should raise the suspicion for a central process as an etiology for vertigo. Some horizontal nystagmus (on extreme lateral gaze) can be a normal finding.

Answer 246

E. Any of the above

The answer is E. This patient has symptoms consistent with benign positional vertigo. It is caused by vestibular stimulation, usually from loose debris in the semicircular canals. Benzodiazipines are useful because of their sedative effect on the limbic system, thalamus, and hypothalamus. Vestibular neurons are mediated by acetylcholine; therefore, anticholinergic agents (e.g., meclizine, diphenhydramine, promethazine) are effective to minimize vertigo.

Answer 247

C. middle cerebral artery

Answer 248

D. Hospital admission for neurosurgical consultation in the morning

he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus, chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder decompression for symptomatic relief is important, as is analgesia

Answer 249

B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation.

The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon test, where edrophonium is given and the patient’s symptoms are observed to transiently improve. The administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring intubation, frequently for prolonged periods.

Answer 250

C. Nitroglycerin decreases BP by decreasing venous return and cardiac output

The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.

Answer 251

C. 25% in the first hour

The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, defines hypertensive urgency. With end-organs symptoms, as above, the presumptive diagnosis is hypertensive emergency. In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the first hour, thereby alleviating symptoms while not compromising cerebral perfusion.

Answer 252

E. All of the above possible causes must be evaluated for

The answer is E. Seizures have a number of secondary causes, which must be identified and corrected before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse. Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus.

Answer 253

E. inadequate tissue and organ perfusion

The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia, hypotension and altered mental status are all signs and symptoms of shock.

Answer 254

E. Traumatic

The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock states (usually hypovolemic, but also distributive in the case of pericardial tamponade), but there is no “traumatic” shock subtype.

Answer 255

C. Tachycardia

The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased respiratory rate, which occur as the body attempts to maintain perfusion.

Answer 256

A. Supplemental oxygen

The answer is A. The fundamental issue in shock is tissue hypoperfusion and hypoxia. All patients in shock should receive supplemental oxygen initially. Steps to improve oxygenation range from nasal cannula to endotracheal intubation.

Answer 257

C. Are able to maintain their blood pressure better

The answer is C. While the treatment priorities for pediatric and adult shock are similar, there are some differences; thus, a specialized approach to care is often required. The epidemiology is different, since in children shock tends to be caused by trauma and infections. Children’s signs and symptoms may be more subtle than those of adults in shock, rendering the physical examination less reliable in pediatrics. One of the key differences is a child’s ability to maintain blood pressure despite presence of shock.

Answer 258

C. 30%

The answer is C. Some texts divide hypovolemic shock into 4 classes based on the percent of volume loss; Class I is loss of up to 15% of circulating blood volume; Class II is 15-30% loss; Class III, 30-40%; and Class 4, over 40%. In general, blood pressure does not drop until approximately 30% of blood volume is lost.

Answer 259

C. Warm, moist skin

The answer is C. Acute hemorrhage or volume loss is characterized by tachycardia, narrow pulse pressure, poor capillary refill and decreased urine output. Skin tends to be cold and clammy. Late findings include hypotension and altered mental status.

Answer 260

D. 16g catheter in the antecubital fossa

The answer is D. A large short catheter is preferred for volume resuscitation. The ideal line is a large caliber introduced in a large or central vein. A 14g or 16g catheter in the antecubital fossa is considered adequate in most settings. Triple lumen and picc line catheters (the PICC is a peripherally introduced indwelling central catheter) are long, very narrow catheters; the length and narrowness increase resistance to fluid flow.

Answer 261

A. D5W

The answer is A. The goal of IV resuscitation is to restore intravascular volume. Fluids that are isotonic are preferred. D5W is hyptonic, and therefore a poor choice for volume resuscitation.

Answer 262

A. massive hemorrhage > 30%

The answer is A. Blood transfusion can play a vital role in the treatment of hypovolemic shock from acute hemorrhage. It is generally not the first line treatment. It is indicated in massive blood loss or shock that is not responsive to significant crystalloid infusion (2L or 30 ml/kg). Pressors are not indicated in hypovolemic shock. Elderly patients and those with co-morbid illnesses may require blood products earlier than healthy adults.

Answer 263

B. Administer Type O Rh+ blood

The answer is B. Patients in extremis with acute hemorrhage need aggressive fluid resuscitation. After an initial crystalloid bolus, blood products should be initiated. Type O is the universal donor type, with Rh-negative blood reserved for women of childbearing age. Type-specific blood is another option, but usually takes at least 15-20 minutes to obtain; cross-matching of blood takes even longer.

Answer 264

A. Cardiac pump failure

Answer 265

C. Phenylephrine

The answer is C. The goal of therapy is to improve oxygenation, minimize ischemia, improve pump function, and decrease afterload. Dobutamine is the agent of choice in the setting of heart failure. An intra-aortic balloon pump may be a temporizing measure. Phenylephrine would increase afterload and worsen cardiac output.

Answer 266

A. Anaphylactic shock

The answer is A. The patient’s respiratory symptoms, absence of JVD, and vital signs suggest anaphylaxis (distributive shock). The proximity of symptoms to ingestion of food also suggests an allergic reaction.

Answer 267

D. Epinephrine

Answer 268

D. Neurogenic shock

The answer is D. The patient is most likely suffering a spinal cord injury, producing a disruption of the autonomic nervous system leading to vasodilation and hypotension (without the expected tachycardic response). This entity, called neurogenic shock, is a type of distributive shock like anaphylactic shock It is important to rule out other internal injuries in this patient, and then institute therapy with a pressor agent such as phenylephrine.

Answer 269

B. Blood transfusion

The answer is B. Treatment of a spinal cord injury with neurogenic shock includes high dose steroids, IV fluids, immobilization, and potentially pressors. Blood transfusions are generally not indicated, and care must be taken to avoid fluid overload. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 247-248.

Answer 270

E. Cardiac tamponade

The answer is E. The patient has a stab wound to the left chest near the sternum. His hypotension, clear lungs, and JVD suggest an obstructive shock. He likely has cardiac tamponade and needs emergent decompression either with pericardiocentesis or pericardial window.

Answer 271

E. high-dose steroids

The answer is E. This patient is most likely suffering from a septic abortion in which retained products of conception developed a local infection. This infection has now spread systemically causing the systemic inflammatory response and potentially causing sepsis. Immediate intravenous fluids and broad-spectrum antibiotics are necessary; however, steroids are contraindicated in such a situation and could worsen the infection. The patient needs to be taken to the OR urgently to remove the retained products of conception.

Answer 272

E. meningococcemia

The answer is E. This patient's presentation is consistent with meningococcemia. Lyme disease often presents with a rash (erythema chronicum migrans), but that rash has a different appearance (erythema with central clearing). Pemphgus vulgaris is characterized by intraepidermal blistering, and angioedema is seen more in the mucous membranes. Herpes zoster has an appearance of grouped (painful) vesicles on an erythematous base.

Answer 273

A. Decreased urine output

The answer is A. Patients in septic shock have decreased systemic vascular resistance and cardiac index, secondary to endotoxins. They can be hyper- or hypothermic but usually are not normothermic. The pulmonary wedge pressure is often normal or low. Like all shock states, septic shock is generally associated with decreased urine output.

Answer 274

E. Group A beta-hemolytic Streptococcus

The answer is E. Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae are common causes of sepsis. Group A beta-hemolytic Streptococcus is a common agent in pharyngitis but rarely causes sepsis.

Answer 275

A. Pulmonary embolus (PE)

The answer is A. DIC, ARDS, ATN, and high-output CHF are all complications of shock. While PE is always a concern in critically ill patients, it is not particularly associated with sepsis.

Answer 276

C. 100.4 F (38 C)

The answer is C. The hypothalamus regulates body temperature. Fever occurs when the body temperature is raised beyond its normal set point. The upper limit of normal is considered to be 100.4 F or 38 C.

Answer 277

B. UA plus urine culture, LP, antibiotics, and admit

The answer is B. Fever in a child less than 30 days can be a marker for bacteremia, sepsis, and meningitis. Clinical findings are notoriously unreliable in this age group. The work up is fairly straightforward. Blood culture, urine culture and LP are required. After the work up, the child should be started on antibiotics. Ampicillin and gentamycin is the preferred regimen in this age group. In a child 30-90 days old, there is controversy regarding the management algorithm. Some authorities treat all children under 90 days of age the same; others risk-stratify and perform selective work ups.

Answer 278

A. Wolff-Parkinson-White syndrome

The answer is A. T“The classic WPW syndrome consists of tachycardia with the following three features: a short P-R interval (<0.12 second), QRS duration greater than 0.10 second, a slurred upstroke to the QRS complex, referred to as a delta wave.”

Answer 279

E. transcutaneous pacer
The answer is E. Complete AV dissociation requires pacing fast enough for adequate perfusion.

Answer 280

C. Pharmacologic ventricular rate control
The answer is C. “If the patient is stable, the first priority is to achieve ventricular rate control.”

Answer 281

C. Adenosine

The answer is C. “Adenosine, a purinergic blocking agent that causes acute and transient AV nodal blockade, is the drug of choice for acute termination of AVNRT. Multiple studies have shown that adenosine is nearly 100 percent effective in terminating AVNRT.”

Answer 282

B. Ventricular tachycardia

The answer is B. “Unstable patients with a wide-complex tachycardia should be treated as if ventricular tachycardia is present. “

Answer 283

C. transvenous pacingT

he answer is C. Second degree Mobitz Type II heart block easily degrades to complete heart block. Second degree Mobitz Type II is an atrioventricular-block rhythm in which there are intermittently non-conducted atrial beats not preceded by lengthening AV conduction. It is usually due to a block within the His bundle system. The bradycardia often is unresponsive to atropine and patients tend to require pacing.

Answer 284

C. sinoatrial node

Answer 285

A. a rhythm which requires immediate defibrillation

Answer 286

C. adenosine

The answer is C. The rhythm shown in the EKG is a narrow complex regular
tachycardia. It could also be described as a supraventricular tachycardia (SVT). The
first-line treatments of stable SVT are vagal maneuvers or adenosine. Unstable SVT
(such as that causing hypotension, heart failure, or myocardial ischemia) should be
cardioverted.

Answer 287

C. atrial fibrillation

Answer 288

B. second degree AV block Mobitz Type I

The answer is B. This is second degree AV block (Mobitz I). Note progressive increase in the PR interval until a blocked P wave occurs. Also note the progressive shortening of the R-R interval before the nonconducted beat. This type rhythm is usually due to abnormal conduction within the AV node. Mobitz I block may occur in normal individuals with heightened vagal tone. It may also occur as a drug effect, especially from digoxin, calcium channel blockers, beta-blockers, or other sympatholytics.

Answer 289

B. Atrial flutter

The answer is B. Atrial flutter has a characteristic saw-tooth pattern. It is generally a regular, narrow complex rhythm. The atrial rate is approximately 300. The rate of conduction can be in a fixed or variable ratio, but 2:1 (atrial:ventricular) is common, resulting in a frequently encountered ventricular rate of about 150. This example has a variable block (2:1 to 4:1).
-- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 174-175.

Answer 290

B. first degree atrioventricular (AV) block

Answer 291

D. Wolff-Parkinson-White syndrome

Answer 292

A. right-ventricular ischemia

Answer 293

A. right bundle-branch block

The answer is A. The EKG reveals right bundle-branch block. RBBB are characterized by a prolonged QRS duration, a terminal R wave in V1 and a slurred S wave in leads I and V6. Frequently, an RSR', or "rabbit ears" pattern can also be seen in the precordial leads.

Answer 294

E. Take measures to relieve pain and recheck the blood pressure

The answer is E. Emergency department therapy should not be instituted based upon a single blood pressure measurement. This is especially true in cases where a patient has a reasonable physiologic explanation (i.e. pain) for elevated blood pressure and other vital signs consistent with pain-mediated sympathetic stimulation. Due to the risk of over-reduction in blood pressure, sublingual agents are rarely appropriate for emergency therapy of hypertension; however, it would be premature to treat the patient with any medication. Asymptomatic patients with elevated blood pressure usually require no cerebral imaging. Additionally, asymptomatic patients usually do not require emergency pharmacologic therapy; even if such therapy is considered the initial abnormal blood pressure should first be rechecked.

Answer 295

A. an elevated arterial pressure associated with end organ damage

The answer is A. A hypertensive emergency is defined by the association of elevated blood pressure with end-organ damage, rather than a specific blood pressure reading. Acute end-organ damage associated with a hypertensive emergency (also known as malignant hypertension or hypertensive crisis) can include: hypertensive encephalopathy, intracerebral hemorrhage, hypertensive retinopathy, heart failure and associated pulmonary edema, acute coronary syndrome, acute renal failure, aortic dissection, and eclampsia.

Answer 296

A. arterio-venous nicking

The answer is A. Increased cup-to-disk ratio is seen commonly in patients with glaucoma, but this finding is not associated with acute or chronic hypertension. Systemic hypertension can affect the retinal, choroidal, and optic nerve circulations, with the degree of vascular change depending on the severity and duration of the hypertension. Linear or flame-shaped hemorrhages and cotton-wool patches (caused by infarction of the nerve fiber layer resulting from arteriolar occlusion) are relatively common. Long-standing hypertension can produce sclerotic changes in the vessel walls; this is manifest as a copper or silver discoloration of the arterioles. Lipid (hard) exudates result from abnormal vascular permeability associated with hypertension. Optic disk edema, indicating infarction and hypoxia of the optic disk, is a hallmark of malignant hypertension.

Answer 297

B. The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction

The answer is B. Patients with acute aortic dissection who require antihypertensive therapy are usually treated with a combination of a beta-blocker (e.g. propanolol) and a vasodilator (e.g. nitroprusside). Though the specific blood pressure goal varies, most patients should have systolic pressure lowered to at least 120 (some prefer even more dramatic absolute systolic blood pressure goals, as low as 100 or less). Patients with hypertensive emergencies are usually treated with a goal of 20-25% reduction in blood pressure over 30-60 minutes, and patients with hypertensive urgencies should have blood pressure lowered over a longer period (hours to days). Sublingual nifedipine, formerly frequently utilized for mild hypertension, has been more recently identified with potentially dangerous blood pressure reduction "overshoot" (and resultant cerebral hypoperfusion), thus this agent is falling out of favor.

Answer 298

C. Obtain a medication history

The answer is C. Sublingual nifedipine risks overzealous blood pressure reduction, and this patient does not have indication for emergent therapy. Similarly, it would be premature to institute therapy with an oral beta-blocker agent based on a single presentation. Elevated plasma levels of free metanephrine and catecholamines, along with the clinical presentation, could point to pheochromocytoma as a possible etiology. The pheochromocytoma workup may include abdominal CT and/or clonidine suppression testing. However, certain medications (such as viral upper respiratory "cold" medications which this patient may have taken, given her symptoms) can also cause the symptoms of this patient. Therefore, further workup or treatment should occur only after a thorough medication history.

Answer 299

D. an alpha-and beta antagonist

D. Labetalol is a non-selective beta-blocker that also possesses alpha-blocking effects. Metoprolol, atenolol, and esmolol are examples of beta1-selective beta-blockers. Esmolol has an elimination half-life of minutes.

Answer 300

A. beta-adrenergic receptor blocker

The answer is A. Elevated urinary metanephrines in this patient strongly suggest the diagnosis of pheochromocytoma. Initial control of her hypertension should be undertaken with an alpha-adrenergic receptor blockade, or alternatively nitroprusside, calcium channel blocking agents or ACE-inhibitors. Beta-adrenergic blockage should only be given AFTER alpha blockade, to avoid paradoxical increases in blood pressure due to antagonism of skeletal muscle vasodilation. While other agents listed may or may not be optimal for initial blood pressure control, the drug type with the strongest contraindication is the beta-blocker.

Answer 301

D. 75% of the pretreatment mean arterial pressure (MAP)

The answer is D. Malignant hypertension, being defined as hypertension with progressive or severe end-organ damage, usually occurs with a diastolic pressure greater than 130 mmHg. The patient’s MAP should be reduced by approximately 25% in the initial treatment phase, avoiding an excessive drop in pressure which could cause renal or cerebral hypoperfusion. Subsequently, the patient’s blood pressure should be dropped to approximately 160/100 in the first 2 to 6 hours of treatment.

Answer 302

A. esmolol IV 100-500 mic/kg load

The answer is A. Hyptertensive emergencies require treatment with IV agents, primarily for their fast onset of action and ability to be titrated. One would generally not choose an oral agent, such as metoprolol or clonidine, if the other options were available.

Answer 303

B. Discharge home with analgesics and an antiviral.

The answer is B. This patient has herpes zoster, commonly known as shingles, which begins as an erythematous rash and after as many as several days becomes vesicular. Shingles can often present after minor trauma, which is thought to reactivate latent varicella-zoster virus. While this patient may relate pain and symptoms to the fall, her ability to ambulate without problems and lack of pain directly after the fall make obtaining an X-ray and referral to orthopedics unnecessary. (Although it may be possible for a patient to ambulate on an impacted hip fracture, the clinical picture points away from orthopedic trauma.) The rash appearance renders a simple ecchymosis or contusion (choice A) unlikely. The characteristic dermatomal distribution of this rash makes a bacterial infection (choice D) much less likely than herpes zoster. Shingles was classically treated with analgesics only, but addition of acyclovir (choice B), if begun within the first several days of the rash, can reduce the incidence of post-herpetic neuralgia.

Answer 304

B. stasis dermatitis

The answer is B. This patient’s presentation may be confused with cellulitis but is in fact stasis dermatitis. The facts that his rash is bilateral and associated with varicose veins and lack of fever increase the likelihood of a long-term process such as stasis dermatitis (chronic inflammation of the skin due to venous insufficiency). Microvascular changes hinder the delivery of oxygen to the skin and subcutaneous tissues. A secondary bacterial infection can be superimposed upon stasis dermatitis. Necrotizing fasciitis is more likely characterized by a rapid progression of extreme pain and blister/bullae formation that represents widespread tissue destruction; patients often are visibly toxic. The hallmark of eczema is pruritis, and psoriasis would appear as white or silvery, flaky patches, neither of which are present.

Answer 305

D. smallpox

The answer is D. The clinical presentation is more consistent with smallpox than any of the other etiologies. Insect bites may have been possible with the initial skin presentation but are much less likely given the spread of the process and the other symptoms. Erythema multiforme is rendered unlikely by the absence of drug ingestion. With chickenpox, fever occurs with the onset of the rash, which is characterized by simultaneous existence of individual lesions at differing stages. Also with chickenpox, the eruption is concentrated over the torso, and given the time course of this example, crusting should have been present if the patient had chickenpox.

Since smallpox has been eradicated worldwide, any cases that do occur (e.g. secondary to terrorist activity) are likely to be misdiagnosed as clinicians are unfamiliar with the disease. After a mean incubation period of 1.5-2 weeks, there is a 2-3 day prodromal phase characterized by abrupt onset of severe headache, backache, and fever. The temperature subsides over 2-3 days. An enanthema over the tongue, mouth, and oropharynx precedes the skin rash by a day. The skin rash begins as small, reddish macules, which become papules with a diameter of 2 to 3 mm over a period of one or two days; after an additional 1-2 days, the papules become vesicles with a diameter of 2 to 5 mm. The lesions occur first on the face and extremities but gradually spread to cover the body. Pustules that are 4 to 6 mm in diameter develop about four to seven days after the onset of the rash and remain for five to eight days, followed by umbilication and crusting. As occurred in this example case, there may be a second, less pronounced temperature spike five to eight days after the onset of the rash, especially if the patient has a secondary bacterial infection. Smallpox lesions have a peripheral or centrifugal distribution and are generally all at the same stage of development. Death from smallpox is ascribed to toxemia, associated with immune complexes, and to hypotension.

Answer 306

E. corticosteroids

The answer is E. The syndrome described is the spectrum of erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis. Although the etiology is not always clear, many drugs (including sulfa antibiotics, penicillins, and barbiturates), viral or Mycoplasma infections, and recent immunization have been implicated. Corticosteroids are a controversial adjunct in treatment, but have not been implicated as a cause of the disease.

Answer 307

D. intravenous ampicillin-sulbactam

The answer is D. Gram-positive bacteria (Streptococcus species and S. aureus) most commonly cause cellulitis in non-diabetic hosts. Penicillinase-resistant penicillins (e.g. dicloxacillin, nafcillin, oxacillin) or 1st-generation cephalosporins (cephalexin, cefazolin) can effectively treat cellulitis. However, in diabetics with recurrent cellulitis, the infection is more likely to be polymicrobial and involve gram-negative organisms. A broader-spectrum antibiotic (e.g. ampicillin-sulbactam) with coverage of gram-positive and gram-negative bacteria is recommended. Gentamicin alone is not effective against gram-positive bacteria.

Answer 308

D. initial therapy often consists of high dose topical steroids

The answer is D. Initial therapy for seborrheic dermatitis is application of anti-dandruff shampoo lathered onto the area and left on for 5-10 minutes. Shampoos can contain zinc pyrethrin (Head and Shoulders), selenium sulfide (Selsun Blue), salicylic acid (Neutrogena T-Sal) or tar (Polytar or Neutrogena T-Gel). The other answers are all correct regarding seborrheic dermatitis.

Answer 309

B. pityriasis rosea

Answer 310

E. All of the above

Answer 311

A. Potency is measured by the ability to induce vasoconstriction.

The answer is A. Corticosteroids are classified into seven groups. (I is the strongest; VII, the weakest). Each steroid’s ability to cause vasoconstriction determines classification. To achieve large differences in potency, it is better to switch agents, as varying the dose of a particular agent does not affect potency as much. In general, vascoconstriction in response to corticosteroid use has been shown to decrease over time, a process known as tachyphylaxis. Therefore, interrupted application schedules are preferred (application for 2 weeks, then 1 week without application). Hydrocortisone is a relatively low potency steroid and does not adequately penetrate thickened parts of the skin such as the sole or palm. Fluorinated steroids are to be avoided in pregnant women.

Answer 312

D. Oral doses of antihistamines should be encouraged initially.

The answer is D. Oral administration of diphenhydramine or hydroxyzine (25 to 50 mg po q6H) is an appropriate adult dose and is effective for pruritis. Intravenous administration can also be used. Topical antihistamines are quickly absorbed, making it difficult to predict the actual dosing if a patient aggressively applies the preparation. Thus, use over large areas of the body should be avoided especially if the patient is currently taking oral antihistamine. The bath or soaking therapies are also recommended to control large areas of pruritis. Second generation antihistamines, although more costly, have lower dosing frequency requirements and cause less sedation.

Answer 313

A. Creams are a mixture of oils, water and preservatives and are best used for acute rather than chronic conditions.

Answer 314

B. A Tzanck preparation can distinguish Herpes simplex virus from herpes zoster virus infection.

Answer 315

C. Death from this condition is very rare.

The answer is C. Mortality from this condition has been reported as high as 10%. If this diagnosis is suspected, immediate dermatology consultation should be obtained.

Answer 316

C. Characteristically the rash begins on the trunk and spreads to the extremities.

The answer is C. Rocky Mountain Spotted Fever characteristically begins on wrist, forearms, and ankles. Within 6-18 hours, the rash spreads centripetally to the arms, thighs, trunk, and face.

Answer 317

D. Antibiotic therapy is contraindicated because it may exacerbate the underlying condition

The answer is D. This condition is commonly associated with secondary bacterial infection and antibiotics may be indicated if signs of superinfection (i.e. surrounding erythema) are present.

Answer 318

B. avoidance of contact with the rash to reduce spreading of the oleoresin antigen

The answer is B. This patient has developed allergic contact dermatitis, a type-IV hypersensitivity reaction, likely due to poison ivy or poison oak exposure. Although the rash can be expected to resolve on its own (i.e. without medical intervention) in 1-2 weeks, relief of this patient’s symptoms can be facilitated with continued antihistamine therapy and/or oral steroid treatment. The bullae can be drained for cosmetic purposes, but the tops should not be removed to avoid risk for bacterial superinfection. This condition is due to exposure to allergenic plant oleresins, which may remain on the clothing that the patient was wearing at the time of contact; thorough washing should therefore be recommended. The allergen is not present in the bullae of vesicles and so, after the initial washing of the involved site, contact with the rash does not cause it to spread.,

Answer 319

E. zinc

The answer is E. Low blood levels of potassium, magnesium, calcium, phosphorus, and zinc can occur as a consequence of dietary deficiency and/or acid-base imbalances in alcoholics. Hypokalemia can cause periodic muscle paralysis and areflexia. Hypocalcemia can cause tetany and weakness. Low phosphorus levels can contribute to myocardial dysfunction, CNS symptoms, muscle weakness and bleeding disorders. Hypomagnesemia can cause a clouded sensorium and other neurological deficiencies. Chronic zinc deficiency leads to the dermatologic consequences described in this patient, including patches and plaques of dry, scaly, sharply marginated and brightly red eczematous dermatitis evolving into vesiculobullous, pustular, erosive, and crusted lesions that initially involve the perioral and anogenital areas. Progression can involve the scalp, hands, feet, trunk and flexural regions. There may be diffuse alopecia and graying of remaining hair. Nail manifestations may include loss of nails or paronychia. A red, glossy tongue is common, and the oropharynx may reveal aphthous-like ulcers. Patients with zinc deficiency tend to be photophobic, irritable, and depressed. Treatment of zinc deficiency consists of dietary or intravenous zinc salt supplementation for 2-3 weeks.

Answer 320

E. pemphigus

The answer is E. Pemphigus is likely an autosomal condition involving antibodies directed at intercellular substance. Significant damage to the epidermis may subsequently lead to dehydration, sepsis, or even death. The other options are known to be associated with internal malignancy. For each condition, there may be several types of malignancy it can be associated with.

Answer 321

D. Initial diagnosis is usually made by Gram’s stain analysis.

The answer is D. Diagnosis of cutaneous anthrax is usually made on a clinical basis, often after determining patient exposure while taking the history. In the future, PCR methods may become widely available and useful to make definitive diagnoses. Treatment for cutaneous anthrax is aimed at preventing the dissemination of a disease which is complicated by a significantly higher mortality.

Answer 322

B. Steroids should always be used in treatment to avoid possible anaphylaxis.

The answer is B. Precipitants of urticaria include food allergies, cold induced, malignancy, SLE, familial, exercise, excessive heat, etc. Drug-induced urticaria does not represent anaphylaxis or indicate its impending development so steroids are usually not indicated. Treatment may only include stopping the offending drug and administering antihistamines or other antipruritics as needed. Although penicillins and opiates are the most common precipitants, drug-induced urticaria has been demonstrated after use of an enormous number of medications.

Answer 323

C. urgent or next-day outpatient follow-up in Dermatology Clinic

The answer is C. The patient’s history and presentation are highly suggestive of malignancy.

Answer 324

E. Stevens-Johnson syndrome

Answer 325

C. Steroids are usually indicated in adults.

The answer is C. The patient's presentation is most consistent with ITP (immune thrombocytopenic purpura). Platelet transfusions can induce inflammatory (autoantibody) response and worsen the patient's condition by increasing platelet destruction. Intracranial hemorrhage is the most feared complication of ITP, and intracranial bleeding is a risk even if levels do not fall as low as 2,500/mm3 (20,000/mm3 is a commonly cited threshold for spontaneous intracranial bleeding). The PT is expected to be normal, and intra-articular bleeding is not a major feature of ITP.

Answer 326

A. Trauma

The answer is A. There are many non-infectious causes of fever. PE, CVA, thyroid storm and NMS are all classic non-infectious causes. Trauma generally does not cause fever. Hypothermia (environmental) tends to be of more concern.

Answer 327

E. WBC is a poor discriminatory predictor of serious bacterial infection.

The answer is E. WBC is a commonly ordered test in the setting of infection. However, it lacks the sensitivity and specificity to be a good discriminatory test for serious bacterial infection. It is more reflective of, and an important marker for, the body’s response to the infection

Answer 328

E. If the infection is bacterial, the primary role of antibiotic therapy is to prevent complications

The answer is E. Pharyngitis is a common infection in children. Viruses cause the majority of cases. The most common bacterial cause is Group A strep. It is very hard to distinguish bacterial versus viral infections based on clinical grounds. Antibiotics do not significantly alter clinical course; however, they reduce complications such as rheumatic fever and glomerulonephritis. Penicillin is the treatment of choice. There is no vaccine for Group A strep.

Answer 329

E. antibiotics and airway management

The answer is E. A child presenting to the emergency department with stridor most likely has croup, with epiglottitis being a less common – but more serious – etiology. Croup tends to be the etiology in younger, nontoxic-appearing children, who usually have a characteristic barking (“seal”) cough. Treatment of croup includes cool mist (though the literature supporting this is limited), racemic epinephrine (which is probably no better than nebulized l-epinephrine), and steroids. Epiglottitis is a true emergency. It presents in children who are older, with high fever, and who are ill appearing. One of the key clinical features is drooling, which indicates swelling and pain interfering with handling of secretions. Children with epiglottitis are at risk of airway obstruction and need early airway management, preferably while the problem is still urgent (as opposed to during catastrophic deterioration) and preferably in the operating room. A lateral soft tissue X-ray would most likely reveal signs of an inflamed epiglottic region (e.g. thumbprint sign). Epiglottitis is a bacterial infection treated with antibiotics.

Answer 330

D. Staph. aureus

Answer 331

E. blood cultures, vancomycin, and admission
The answer is E. Infective endocarditis has a very high morbidity and mortality if untreated. IVDA with a fever represent a special population at risk. Many emergency departments routinely admit IVDA with a fever even without other findings suggestive of endocarditis. Given the patient’s fever and murmur, he should receive blood cultures, IV antibiotics and admission.

Answer 332

B. Macrodantin (nitrofurantoin)

Answer 333

D. Pyelonephritis

Answer 334

B. Neisseria gonorrhea

Answer 335

B. Lyme disease

Answer 336

B. Rocky Mountain spotted fever

Answer 337

C. Varicella

Answer 338

A. Rotavirus and Norwalk virus

Answer 339

E. Staph. aureus

Answer 340

E. Admission for intravenous antibiotics and probable surgical clean-out are indicated.

The answer is E. This patient has purulent drainage from an infected finger, and will likely not have painless range of motion. The patient may have a foreign body in the wound (most glass is radiopaque) and the history may not be reliable (e.g. a “fight bite” injury remains a possibility). The lack of fever is somewhat reassuring but does not translate into appropriateness of outpatient management given the severity of infection, the anatomical location, and the patient’s doubtful follow-up. There is high likelihood of involvement of important structures, including the joint space, and a digital infection of this type requires admission and surgical subspecialty consultation.

Answer 341

E. parotitis

Answer 342

C. The rapidity of symptoms’ onset does not correlate with the likelihood of need for airway intervention.

Answer 343

B. large amounts of visible pus in the submandibular space

Answer 344

D. Stapholococcus aureus retropharyngeal abscess

The answer is D. This patient exhibits several classic symptoms of retropharyngeal abscess including fever, neck stiffness, and drooling, as well as her generally toxic appearance. Retropharyngeal abscess in children is often associated with foreign body ingestion leading to perforation of the hypopharynx or esophagus. Pneumonia, viral croup and upper respiratory tract infection are unlikely to cause airway obstruction, which is suggested by this patient’s drooling. Choanal atresia is typically diagnosed in infancy. Another consideration in this patient would be epiglottitis; however, given her vaccination history, she would be less likely to contract epiglottitis from H. influenzae Type b, which is the most common causative organism.

Answer 345

C. incision and drainage

The correct answer is C. This patient has a felon, an infection of the pulp of the distal finger or thumb. It differs from other subcutaneous abscesses because septa divide the pulp into small fascial compartments. These septa must be divided during the incision and drainage. An incision should be made along the ulnar aspect of digits II-IV and the radial aspect of digits I and V to avoid the pincher surfaces. The incision should be posterior to the digital artery and nerve.

Answer 346

A. erythema of the flexor surface of the involved digit

The answer is A. Other than swelling of the involved digit, there may be little external evidence of a deep space flexor tenosynovitis.

Answer 347

A. There is a vaccine available for U.S. use, which is active against a disease transmitted by this insect

The answer is A. This patient had an engorged tick (identified as an Ixodes, or deer tick, by the hospital’s pathology department) on the leg. The Lyme disease vaccine, though not yet widely utilized, is available for administration. Removal of ticks is a topic that’s often discussed, with varying approaches put forth, but there is in fact little evidence-based support for most removal techniques. One widely referenced procedures book (Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 3rd edition, pages 631-632) contends that no technique is better than simple mechanical removal of the tick with forceps. Likelihoods of various tick-borne disease possibilities vary with geographic locale, and thus indications for prophylactic antibiotics also tend to vary. However, it is not uncommon for ticks to simultaneously transmit more than one disease (e.g. Lyme disease and babesiosis).

Answer 348

D. Removal of the foreign body with a moistened cotton swab
The answer is D. The cornea is one of the most sensitive parts of the body.
Tiny foreign bodies (such as the one in the Figure) lying on the surface of the cornea or on the underside of the eyelids can cause tremendous discomfort as they stimulate thousands of corneal nerve fibers with each blink. The patient may not see the foreign body but will complain of tearing and conjunctival reddening.
It is important to differentiate between intraocular and extraocular foreign bodies.
Intraocular foreign bodies (those that penetrate the globe) may diminish visual acuity by distorting the lens or by causing a vitreal hemorrhage. Extraocular foreign bodies are unlikely to diminish visual acuity unless they lie directly in the visual axis (in line with the pupil). In either case, the patient presenting to the emergency department with a suspected ocular foreign body should receive an eye examination that includes testing of visual acuity while the patient wears corrective lenses (not contact lenses).

The proper management of a suspected foreign body includes eversion of both
lids, which in this case, resulted in identification of the foreign body. A moistened cotton swab easily removes a foreign body on the palpebral conjunctiva. Fluorescein should then be applied to the cornea. Using a magnifying glass or a slit lamp, examine the cornea for epithelial defects. If a corneal abrasion is identified, the patient should refrain from wearing contact lenses until it has healed. Wearing contact lenses over a corneal epithelial defect predisposes the patient to forming an infectious corneal ulcer. There is no need to patch the eye because patching confers no benefit in healing corneal abrasions.

Answer 349

C. You note a small puncture wound in the globe

Answer 350

D. ophthalmology consultation for intraocular foreign body

Answer 351

A. ultraviolet keratitis

The answer is A. Ultraviolet (UV) keratitis constitutes a sunburn of the cornea. Common exposures include welding torches, sun-tanning booths, prolonged sun exposure (i.e.; high altitude skiing without ski goggles). The classic presentation of UV keratitis is that of a “red” eye – incredibly injected conjunctiva, eye pain, and photophobia. Central retinal artery and vein occlusion, retinal detachment, and vitreous hemorrhage affect structures deep to the conjunctiva and generally do not cause conjunctival injection.

Answer 352

A. vertical corneal abrasions

Answer 353

C. The patient’s right eye sees at 20 feet what a normal eye sees at 200 feet.

Answer 354

A. Irrigate copiously with normal saline.

Answer 355

A. It is an ester.

he answer is A. It is an ester. It is important to ask all patients to whom you are considering administering a topical anesthetic about anesthetic allergy. Since proparacaine is an ester, it would be safe to use in patients with amide allergy history. It is not prescribed for home-going use, as it has been shown to slow the corneal healing process. Proparacaine drops are clear, not orange (fluorescein strips will stain tears orange). There are no systemic effects when used in appropriate dosages.
-- For further reading, see Micromedex.

Answer 356

A. acute angle closure glaucoma

Answer 357

B. oral steroids are indicated for treatment

Answer 358

C. prednisone 100 mg PO QD

Answer 359

B. Its diagnosis hinges on temporal artery biopsy

Answer 360

B. ipsilateral forehead weakness

Answer 361

E. hyphema

Answer 362

A. central retinal artery occlusion

Answer 363

D. corneal ulcer

Answer 364

D. proparacaine

The answer is D. Topical anesthetics should not be prescribed for pain relief, as many cause corneal toxicity when recurrently dosed. Cycloplegic agents like homotropine and cyclopentolate reduce ciliary spasm and offer tremendous relief. OTC and prescription analgesics also work.

Answer 365

E. lumbar puncture

The answer is E. Young obese women are predisposed to pseudotumor cerebri - a disease characterized by increased ICP, normal CT, papilledema, normal CSF. Causes include: pregnancy, medications (OCPs, steroids, vitamin A). Sequelae include visual field cuts.

Answer 366

B. ophthalmoplegia

Answer 367

A. mydriatic agents

The answer is A. In fact, mydriatic agents are contraindicated. Miotic drops, like Pilocarpine by contrast, are used. Other agents employed in the treatment of AACG include: carbonic anhydrase inhibitors (decreased aqueous production), topical beta cblockers (decreased aqueous production), mannitol (decreased intraocular pressure), and iridectomy

Answer 368

E. tropicamide

Answer 369

B. Boxer’s fracture

Answer 370

B. Salter II

Answer 371

A. acromio-clavicular separation

Answer 372

B. comminuted

Answer 373

D. pathologic fracture

The correct answer is D. A fracture that occurs through abnormal bone is called pathologic. This should be suspected whenever a fracture occurs with minimal trauma. Metastatic carcinoma is the most likely cause of this patient’s abnormal bone. Osteoporosis, scurvy, enchondromata, giant cell tumor, cysts, osteomalacia, osteogensis imperfecta, rickets and Paget’s disease all weaken bones and may lead to pathologic fractures.

Answer 374

A. greenstick fracture

Answer 375

C. a third degree sprain

The correct answer is C. A first degree sprain is minor tearing of the ligamentous fibers with mild hemorrhage and swelling. A second degree sprain is a partial tear of a ligament causing moderate hemorrhage and swelling, tenderness, painful motion and loss of function. A third degree sprain is complete tearing of a ligament resulting in grossly abnormal joint movement in addition to hemorrhage, swelling and pain.

Answer 376

E. all of the above

Answer 377

A. calcaneous

e correct answer is A. The calcaneous is the most commonly fractured tarsal bone. Most of these fractures are caused by falls with direct axial compression. Boehler’s angle is the angle measured on the lateral view as the angle between two lines -- one between the posterior tuberosity and the apex of the posterior facet, and the other between the apex of the posterior facet and the apex of the anterior process. If this angle is less than 20 degrees, a compression fracture of the calcaneous should be suspected.

Answer 378

C. lumbar compression fracture

Answer 379

A. 5th metatarsal tuberosity fracture

Answer 380

E. obtain another view of the forearm, and also X-ray the elbow and wrist

The correct answer is E. This patient has an ulnar fracture, which like any other fracture should be imaged in at least two planes. Additionally, views of the wrist and elbow are indicated to assess for fractures or dislocations to joints adjacent to the injury.

Answer 381

A. limited ability to extend the leg

The correct answer is A. The X-ray demonstrates patella alta, or a high-riding patella. This X-ray finding, which is associated with patellar tendon rupture, is defined as being present when the ratio of the patellar height to the (apparent) length of the patellar tendon exceeds 1:1.2. Patella baja, a low-riding patella, is the finding when the quadriceps tendon is ruptured (in these cases there will often be a palpable defect superior to the patella). Patellar tendon rupture is less common than quadriceps tendon rupture, and patellar tendon rupture is more likely in younger patients (<40 years) while quadriceps rupture more frequently occurs in older patients.

Answer 382

E. elbow dislocation

Answer 383

A. A: subcapital B: basilar neck C: intertrochanteric D: subtrochanteric

Answer 384

D. Treating physicians should search for other signs of nonaccidental injury and consult child protective services.

Answer 385

D. biceps rupture

Answer 386

A. arthrocentesis

Answer 387

B. Phalen’s test/carpal tunnel syndrome

Answer 388

E. The patient has pseudogout.

The answer is E. The figure depicts chondrocalcinosis, which is most likely indicative of pseudogout. However, due to the possibility of co-existing infection, arthrocentesis is indicated to confirm the diagnosis and rule-out joint space infection. Blood cultures are not expected to be positive in pseudogout without infection, and in fact blood cultures are often negative even in the presence of a septic joint. There is no radiographic evidence of knee replacement, and meniscal tear is not commonly associated with radiographic findings.

Answer 389

A. A Salter-Harris V fracture occurs when there is compression of the bony area marked "C" towards the bony area marked "B".

Answer 390

D. Colchicine may result in symptomatic improvement in patients with either gout or pseudogout.

Answer 391

B. Radiographic imaging for suspected retained foreign body

Answer 392

C. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function

Answer 393

E. Retinal hemorrhages are a common finding in mild-moderate trauma.

Answer 394

C. Orthopedic consultation for possible open reduction and internal fixation (ORIF)

Answer 395

B. Salter II

Answer 396

C. Apply pressure to the radial head while flexing and supinating elbow

Answer 397

B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity)

Answer 398

D. bradycardia

Answer 399

B. alkalosis (as assessed via fetal scalp capillary monitoring)

Answer 400

D. have his/her trachea suctioned.

The answer is D. In order to prevent aspiration of meconium, the infant should have his/her airway suctioned. (This recommendation is the standard of care at this time, but is becoming somewhat controversial. Some believe the introduction of the endotracheal tube may further contaminate the distal respiratory tract with meconium.) Using a bag-valve mask before suctioning could precipitate meconium aspiration. A dose of penicillin should not delay resuscitation. Doxycycline is contraindicated in patients younger than 8 years. Swaddling and placing of the newborn in an incubator helps to prevent hypothermia.

Answer 401

A. Chest compressions should be initiated whenever an infant’s heart rate is less than 60 bpm.

Answer 402

B. digoxin

The answer is B. The drugs which may be given by endotracheal route can be remembered by the mnemonic “LEAN” — lidocaine, epinephrine, atropine, naloxone. Up to 10 times the IV dose diluted to 5mls and followed by 3-5 positive pressure breaths is necessary to achieve equivalent plasma concentrations. Digoxin must be given by the IV route.

Answer 403

A. asystole

Answer 404

C. epinephrine infusion

The answer is C. While dopamine is the drug of choice in adults, epinephrine infusion is the initial treatment of choice in pediatric patients. As coronary artery disease is rare in children, there is less of a concern regarding its dysrhythmogenic effects and the risk of myocardial infarction. Dobutamine and dopamine infusions also play a role in resuscitating the hypotensive child, but are not first choice agents. Dobutamine bolus alone and nitroprusside have no role to play.

Answer 405

E. hyperglycemia
The answer is E. Due to low fat stores, inability to generate heat by shivering, and relatively large surface-to-volume area, the newborn infant is not easily able to maintain body temperature. Metabolic acidosis, increased oxygen consumption, hypoglycemia, and apnea are all physiologic consequences of hypothermia.

Answer 406

C. heart rate of 95

The answer is C. Bradycardia (defined in Rosen’s text as a heart rate of <100) can be a critically important manifestation of neonatal distress; therefore, caregivers must be familiar with expected vital signs in newborns.

Answer 407

D. dry, warm, position, suction, stimulate

Answer 408

E. Drug delivery by endotracheal route is preferred over the intraosseous route

Answer 409

C. Speculum examination of the nares

Answer 410

D. removal of foreign body

coin in there

Answer 411

D. Ask the mother if she has any bleeding from her nipples.

Answer 412

C. arrange for a barium enema and surgical consultation

The answer is C. This child has the classic presentation for intussusception, which is the telescoping of one portion of the intestine into another, cutting off blood supply to the intestine. Classically the patient is 3 months to 6 years in age and has episodes of intermittent abdominal pain and cramping. The characteristic currant jelly stool is a late and infrequent finding. Barium enema is both a diagnostic and often therapeutic procedure, but it can result in perforation; thus, pediatric surgery consultation should occur in conjunction with ordering this test.

Answer 413

D. hypoxemia

Answer 414

E. tachycardia
The answer is E. Hypoxemia in newborns may present differently than the same process in adults. Like adults, neonates with hypoxemia may exhibit cyanosis, lethargy, and unresponsiveness, but unlike older patients the heart rate tends to be slow rather than fast.

Answer 415

C. maternal drugs

Answer 416

C. 6 mm

he answer is C. The correct endotracheal tube size can be approximated by using a simple formula: Inside diameter (ID) in mm = (16 + age in years) / 4. As this is an estimate, it is prudent to have the next smaller and larger size endotracheal tubes available as well. Estimation of tube size based on the size of the patient’s fifth finger is less accurate. The tube size may also need to be modified based upon the etiology of the arrest (e.g. airway narrowing from infectious disease).
-- For further reading, see Fleisher’s Textbook of Pediatric Emergency Medicine, 3rd edition, pages 8-12.

Answer 417

B. tracheoesophageal fistula

Answer 418

B. back blow then chest thrust

Answer 419

C. 5-minute Apgar score of 5-7

Answer 420

C. The pediatric airway is more posterior than the adult airway.

The answer is C. The pediatric airway is more anterior than the adult airway. The other choices (A, B, D, and E) are all correct regarding the pediatric airway as compared to that of the adult.

Answer 421

C. Due to the fragility of the pediatric C-spine, a cervical collar should always be placed prior to intubation for children under age ten.

Answer 422

C. age in months divided by 3

Answer 423

A. Atelectasis of the affected lung

Answer 424

D. Objects lodged in the proximal airway have the worst prognosis

The answer is D. Large objects in upper airway and trachea have the worst prognosis and typically present with the most severe symptoms.

Answer 425

E. hypovolemic

Answer 426

B. penicillin

Answer 427

A. albuterol inhaler 2 puffs every 4 hours

Answer 428

B. Administer magnesium sulfate

The answer is B. This patient falls in the category of severe pre-eclampsia, which is a form of pregnancy-induced hypertension. It is characterized by hypertension with proteinuria or pathologic edema. Pre-eclampsia can be categorized as mild or severe. It is diagnosed as severe if one of the following is present: headache unresponsive to analgesics, visual disturbances, diastolic blood pressure over 110 mm Hg, pulmonary edema, elevated liver enzymes, 2+ or greater proteinuria, oliguria, elevated creatinine, hemolysis, or intrauterine growth restriction. Patients with mild pre-eclampsia do not always require hospitalization (choice B), but those with severe pre-eclampsia must be admitted for IV access and fetal monitoring. This patient already shows signs of being in labor with frequent contractions and a dilated and effaced cervix, and thus does not need to be given prostaglandins, which are used to “ripen” the cervix for labor induction. The most urgent management issue for her is prevention of seizures, which can cause permanent CNS damage, intracranial bleeding, and death. Administering magnesium sulfate is the most effective method. Since delivery is the definitive treatment for severe pre-eclampsia, tocolytics such as terbutaline should not be administered. Diuretics such as furosemide are not suggested in this patient, as hypovolemia can cause fetal hypoperfusion.

Answer 429

B. diabetes mellitus

Answer 430

B. Fetal Age

The answer is B. The cure for pre-eclampsia is delivery of the baby, and the fetal age and maturity are the most important factors to consider in determining the planning for delivery. For pregnant women at or near term, induction of labor is usually indicated.

Answer 431

D. respiratory depression

The answer is D. Overdose of MgSO4 can lead to both maternal and neonatal complications including muscle weakness, respiratory depression, and cardiac failure. If renal failure occurs (as a result of severe pre-eclampsia/eclampsia, rather than as a result of MgSO4 itself), plasma concentration of Mg should be followed closely since the kidney excretes Mg. Other toxic effects include loss of deep tendon reflexes, SA and AV node block, respiratory paralysis, cardiovascular collapse and cardiac arrest.
-- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 2423-2424.

Answer 432

B. labetolol

Answer 433

A. nitroprusside

The answer is A. One of the side effects of nitroprusside is cyanide toxicity, and this agent is thus best avoided in pregnancy. Other side effects of these medications include: headache, abdominal and/or chest pain, GI upset, and seizure.

Answer 434

C. HBV core antibody indicates immunity to HBV.

Answer 435

B. Helicobactor pylori

Answer 436

E. all of the above

Answer 437

D. Abnormal vaginal discharge is typically seen on pelvic exam in patients with pyelonephritis.

Answer 438

A. Can be treated with endoscopy

Answer 439

D. Edentulous
The answer is D. Multiple studies have noted that ingested foreign bodies are relatively more common in pediatric, edentulous, incarcerated, and psychiatric patients. No studies that show that asthmatics, tobacco smokers, diabetics, or hypertensives are more likely to ingest foreign bodies.

Answer 440

B. Elevation of the head of the patient’s bed is recommended.

The answer is B. This patient has superior vena cava syndrome, which is usually caused by tumor-related compression on the SVC. Historically, emergent radiation therapy was the major treatment regimen, but chemotherapy is also a therapeutic option. Elevation of the head of the bed has been shown to have immediate salutary effects. Figure A shows the classic facial plethora which may be seen. Figure B reveals a large mediastinal tumor, with caval compression. Patients with SVC syndrome do not seize, unless there are associated mass lesions in the brain. Airway impingement is uncommon in the absence of a tumor or other mass directly compressing the trachea.

Answer 441

C. Order a venogram to rule out a deep venous thrombosis

Answer 442

B. penicillin

Answer 443

E. ketorolac

Answer 444

B. The levels of EMT training and EMT-level nomenclature are the same throughout the United States.

Answer 445

A. is stocked with different supplies and equipment

Answer 446

D. EMS systems operated by a government agency (e.g. a city department of public health) have no malpractice liability.

Answer 447

B. adenosine

The answer is B. This question addresses whether the agents listed are “time-critical” rather than whether or not they "work.” While useful in effecting rate control for tachycardia, adenosine is the least likely of those listed (assuming an indication for their administration) to impact patient outcome when given in the field as compared to being given in the emergency department. Glucose can be life-saving in patients with hypoglycemia. In addition to its use in cardiac arrest, epinephrine can be life-saving when administered, for example, to patients with anaphylaxis. Bronchodilators can help reverse bronchospasm in severe asthmatics. Diazepam (or other benzodiazepines) can be a critical intervention when there is seizure activity.

Answer 448

A. Provide treatment for the child

Answer 449

E. Aggressive fluid resuscitation prior to surgical hemostasis is an absolute standard of care to minimize post-traumatic morbidity.

Answer 450

B. Thrombolytic therapy in the field is the standard of care for patients suspected of having an acute coronary syndrome.

Answer 451

A. Nonphysician crews staff most HEMS vehicles in the United States

Answer 452

A. Flight crew ETI success rates tend to be high in part because of their enhanced drug formulary (e.g. neuromuscular blockade) as compared to most ground EMS units.

Answer 453

B. extracorporeal membrane oxygenation (ECMO

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