ED case files 2

•Meticulous hemostasis is important in repairing ear lacerations to avoid ?

"cauliflower ear."

Bites that are more than ? hours old are, in general, left open, because of the risk of infection.

6

A 38-year-old man presents to the ED after a motor vehicle collision. After complete evaluation it is determined that he sustained a fractured right tibia. The patient has a history of hypertension for which he is on pharmacologic treatment. The patient is writhing on the gurney in pain. His blood pressure is 210/104 mm Hg. The patient has no complaints except for right leg pain. Which of the following is the most appropriate next step in management? A. Pain control and monitor the patient's blood pressure. B. Start a -blocker and monitor the patient's blood pressure. C. Call a social worker because of suspected drug or alcohol abuse. D. Admit the patient to the hospital to get his blood pressure under control

A. Although this man has a history of hypertension, he is in excruciating pain, which could be causing his elevated blood pressure. The appropriate treatment is to control the pain, have the leg set back into place, and monitor his blood pressure. The blood pressure should decrease once his pain is controlled.

A 48-year-old man was rock climbing when he slipped and suffered a laceration to his right lower leg. He put pressure on it, wrapped the area, and made his way to the ED. He recalls getting "all his shots" when he was a child, but doesn't recall the last tetanus booster. Which of the following is the best choice regarding tetanus prevention? A. Diphtheria toxoid/tetanus toxoids (DT) vaccine 0.5 mL IM B. DT 0.5 mL IM and tetanus immune globulin (TIG) 250 units IM C. DT 0.5 mL IM, TIG 250 units IM, and intravenous penicillin 600,000 units every 6 hours D. Admit to the ICU to observe for muscle spasm and administer 2500 units TIG IM and 0.5 mL tetanus toxoid IM in the opposite deltoid muscles

A. Because the patient likely received a full series of immunizations, but does not remember the last booster, he should receive tetanus toxoid 0.5 mL IM. TIG should be reserved for the following patients: those who do not know their immunization status or know that they never received the full series of three shots and sustained a contaminated wound. Admission to the ICU should be considered if the patient has signs of tetanus, such as muscle spasm or lockjaw.

A 20-year-old man involved in a motor vehicle accident is brought into the emergency room having lost much blood at the accident scene. His initial blood pressure is 80/40 mm Hg and heart rate 130 beats per minute. He is given 3 L of normal saline intravenously and is still hypotensive. Which of these statements most accurately describes the pathophysiology of his condition? A. Insufficient cardiac preload B. Insufficient myocardial contractility C. Excessive systemic vascular resistance D. Excessive IL-6 and leukotrienes

A. In situations of trauma and hemorrhage, persistent hypotension is caused by blood loss unless otherwise proven. Hypotension is caused by lack of preload. Preload is end-diastolic sarcomere length, and insufficient circulating volume does not allow for sufficient venous return or cardiac output.

A 58-year-old man experienced a neurologic deficit and is diagnosed as having a stroke. Which of the following is the most likely etiology? A. Ischemic B. Hemorrhagic C. Drug-induced D. Trauma-induced E. Metabolic-related

A. Ischemia is the most common etiology of stroke (due to thrombosis, embolism, or hypoperfusion) and is responsible for up to 80% of strokes.

A scoutmaster brings a boy scout to the ED with a snakebite to his left foot. He says he heard the snake's rattle just before it bit him. His entire foot is purple, swollen to his mid-calf, and very painful to the touch. A. Identify the species, clean and immobilize the site, and administer antivenin. B. Clean bite site and treat with prophylactic antibiotics. C. Clean site, observe animal, and watch for signs of secondary infection. D. Clean the site and begin rabies prophylaxis with active and passive immunization. E. Admit for radical surgical debridement in the operating room.

A. This is a high-risk snakebite. The authorities should immediately be notified to search for the snake. Although some percent of venomous snakebites fail to inject venom, this bite is clearly envenomed. The rapid swelling, pain, and discoloration demands immediate attention. First responders should immobilize the site and place constriction bands that do not obstruct arterial flow. The swelling is not a compartment syndrome unless elevated pressures are measured. Avoid incisions and fasciotomies or packing in ice. Immediate antivenin injection in and around the site should be a priority. Remember that species-specific antivenin is important and that administration time is critical. Best results are obtained within 4 hours. Mark the swelling every 15 minutes, evaluate coagulation profiles, electrocardiogram (ECG), renal function, and liver function, and consider ICU admission to ensure adequate perfusion and to avoid disseminated intravascular coagulation (DIC). An index of antivenin can be obtained from the American Zoo and Aquarium Association ( 301-562-0777 ) as well as your local poison control center ( 800-222-1222 ).

? pain is a common feature in DKA and is usually idiopathic, especially in younger patients.

Abdominal

A 32-year-old woman is noted to have persistent hypotension from suspected toxic shock syndrome despite 6 L of normal saline given intravenously. Which of the following is the best next step? A. Use colloid (albumin) for the next bolus. B. Initiate norepinephrine infusion. C. Administer corticosteroid therapy. D. Transfuse with fresh-frozen plasma. E. Activated protein C.

B. A vasopressor agent such as norepinephrine (or dopamine) is the treatment of choice for hypotension that is unresponsive to intravenous saline infusion. The use of colloids during resuscitation has not been shown to improve outcome compared to crystalloids. Fresh-frozen plasma is not indicated. There is not enough information provided to asses if activated protein C is indicated.

Which of the following is an advantage of the FAST examination in a patient with hemorrhagic shock? A. Can identify retroperitoneal hematomas B. Can be performed quickly at bedside C. Can identify the specific site of injury D. Can quantify the exact amount of blood loss

B. DPL and FAST cannot rule out retroperitoneal injury or identify the specific site of injury, but they can be performed quickly at bedside on unstable trauma patients. To find the specific site of injury and rule out retroperitoneal injury, a CT scan can be done; however, the trauma patient must be hemodynamically stable to be transported to the CT scan suite.

A woman arrives in your ED with a human bite to her breast that occurred earlier in the day. There is a small puncture wound and no signs of cellulitis. A. Identify the species, clean and immobilize the site, and administer antivenin. B. Clean bite site and treat with prophylactic antibiotics. C. Clean site, observe animal, and watch for signs of secondary infection. D. Clean the site and begin rabies prophylaxis with active and passive immunization. E. Admit for radical surgical debridement in the operating room.

B. Human bites have high rates of infectivity. This wound does not appear to be infected. Nonetheless, the wound should be cleaned and 3- to 5-day course of prophylactic antibiotics should be initiated. Human bites rarely lead to retained teeth so a radiograph is not indicated. If this bite occurred on the hand or across a joint space, a radiograph should be performed. Tetanus toxoid should be given if indicated. TDaP has now been approved for use in patients over 65 years old.

An 80-year-old man is being evaluated for possible thrombolytic therapy after presenting with 2 hours of right arm weakness and aphasia. Which of the following is a contraindication for thrombolytic therapy? A. Bilateral cerebral infarct B. Hemorrhagic stroke C. Hypertension-related stroke D. Age of 80 years

B. Indications for tPA administration include an ischemic stroke with a clearly defined time of onset, measurable neuralgic deficit, and a baseline CT with no evidence of intracranial hemorrhage. Contraindications for tPA therapy vary and include: seizure at the time of stroke, history of intracranial hemorrhage, persistent blood pressure >185/110 mm Hg despite antihypertensive therapy, recent surgery or GI bleed, recent MI, pregnancy, or elevated aPTT or INR due to heparin or warfarin use, platelet count <100,000, etc.

Which of the following patients with shortness of breath has the lowest clinical probability for PE? A. A 67-year-old man who underwent bilateral total knee replacements 2 weeks ago B. A 38-year-old man who underwent an uncomplicated open appendectomy 3 weeks ago C. A 35-year-old woman with a history of ovarian cancer D. A 35-year-old man with a history of a DVT 15 years ago, which occurred after an accident E. A 26-year-old woman who had an uncomplicated vaginal delivery 10 days ago

B. Malignancy, acquired or inherited hypercoagulable states, previous DVT or PE, immobility, and pregnancy are all risk factors for DVT and PE. Although surgery is a known risk factor, the length of the operation and time of postoperative immobility are factors that contribute to thrombosis. The patient who underwent a noncomplicated appendectomy is at minimal risk for a DVT. Patient with the bilateral knee replacement would have very limited mobility for a long period time putting him at risk for DVT and PE. Patient with ovarian cancer is at risk because of her malignancy. A patient with a previous DVT certainly has a greater lifetime risk for recurrence of a DVT. Patient had a normal vaginal delivery 10 days previously would have a higher risk of DVT than the general population

Which of the following approaches is most appropriate for the clearance of the C-spine in a 25-year-old man who the driver of a car struck from behind? He is hemodynamically stable, nonintoxicated, and has a GCS of 15. A. NEXUS criteria B. Canadian C-spine rule C. CT of the C-spine D. 3-view x-ray of the C-spine E. Remove the collar because he does not have any pain

B. The Canadian C-spine rule (CCR) is an approach developed for the clearance of C-spines in asymptomatic patients following low mechanism events. The CCR has been compared to the NEXUS criteria and found to be more specific and sensitive in clearance of the C-spine.

A 28-year-old insulin-requiring woman is found in her apartment by her husband. She is stuporous and cannot provide any history. EMS is called and takes the patient to the emergency center, and a diagnosis of severe DKA is made. Her blood pressure is 80/40 mm Hg and heart rate 140 beats per minute. The glucose level is 950 mg/dL, potassium level 6 mEq/L, HCO3 4 mEq/L. The patient is undergoing therapy. Which of the following principles is most accurate in the treatment of DKA? A. Isotonic saline with no dextrose should be used during the hospitalization because the patient is diabetic. B. Typically, intravenous insulin and dextrose solution will need to be continued until the acidosis has resolved. C. Potassium replacement is rarely necessary. D. Sodium bicarbonate is helpful to resolve the anion gap more quickly.

B. The serum glucose often drops much more rapidly than the ketoacidosis resolves; insulin is necessary to metabolize the ketone bodies but dextrose prevents hypoglycemia. Potassium replacement is usually necessary, but should wait until hyperkalemia is excluded. Bicarbonate does not hasten resolution of DKA.

A 55-year-old man presents to the ED with complaints of a severe headache, diplopia, and vomiting. His blood pressure is 210/120 mm Hg upon arrival. Which of the following is the best next step? A. Observe the blood pressure and recheck in 1 hour, and supportive measures for the headache and vomiting. B. Obtain a head CT scan, give an antihypertensive such as nicardipine, and admit to the intensive care unit. C. Give intravenous furosemide to decrease the blood pressure. D. Give lorazepam to help the patient relax

B. This man has hypertensive encephalopathy, which is a medical emergency. He has symptomatic hypertension causing end-organ damage. A head CT scan should be obtained prior to starting treatment to rule out any intracranial pathology. The appropriate treatment is IV antihypertensive medications to decrease his mean arterial pressure by 20% to 25% over 1 hour.

A 32-year-old woman is admitted to the hospital for acute pyelonephritis. The patient is treated with oral ciprofloxacin. After 4 days of therapy, she returns to the ED with persistent fever to 38.9°C (102°F) and flank tenderness. The urine culture reveals E coli greater than 100,000 colony-forming units per mL susceptible to ciprofloxacin. When you arrive to examine her, you note that she is tachypneic, tachycardiac, and appears lethargic. Which of the following is the next step? A. Order an intravenous pyelogram. B. Obtain IV access and administer a fluid bolus. C. Initiate a workup for fictitious fever. D. Consult a surgeon for possible appendicitis. E. Add antifungal therapy.

B. This patient is progressing to severe sepsis, and possibly septic shock. While an intravenous pyelogram may be needed eventually to rule out mechanical obstruction (eg, an infected stone) as a cause of this patient's refractory UTI, the urgent need here is prompt fluid resuscitation.

Which of the following statements regarding DVT is most accurate? A. A patient with thrombosis of the superficial femoral vein is never at risk for PE. B. Venography is the definitive test for the diagnosis of DVT. C. Thrombosis of the vena cava, subclavian veins, and right atrium are frequent sources of PE. D. Venous duplex ultrasonography is most useful in diagnosing DVT in the pelvic veins. E. Cancer successfully treated 5 years ago is associated with a higher risk for DVT

B. Venography is the gold standard for diagnosing thromboses of the deep veins of the extremities and is useful when duplex studies are inconclusive in high-risk, high-probability patients. Duplex ultrasonography combines direct visualization of the vein with Doppler flow signals. Part of the study relies on the examiner's ability to visualize compression of the veins to rule out an occluding thrombus. Because intra-abdominal and pelvic veins are difficult to compress, their evaluation by this method is limited. Most clinically significant PE derives from the large veins of the lower extremity, especially the iliofemoral veins that can embolize large clots to the pulmonary vasculature with disastrous hemodynamic consequences. Infrequent sources of PE can be central veins of the upper extremity, the vena cava, or even the right atrium. Despite its name, the superficial femoral vein is considered a deep vein (it accompanies the superficial femoral artery), and can be the source of clinically significant thromboemboli. Active cancer, rather than a history of treated cancer (>5 years) is associated with a higher risk of DVT.

An otherwise healthy 65-year-old woman is taken to the ED with probable stroke. Which of the following are the most urgent diagnostic studies? A. Coagulation studies B. ECG and cardiac enzymes C. Bedside blood glucose and CT scan of the head D. MRI of the head with and without contrast

C. Bedside blood glucose and CT scan of the head are the most urgent diagnostic studies in evaluating possible stroke patients. Coagulation studies, a complete blood count or platelet count should not delay tPA administration unless the patient is taking anticoagulation or has suspected thrombocytopenia. Non-contrast head CT is generally the initial imaging study, not MRI, to exclude hemorrhage or tumor as a cause of neurologic deficits. Though MRI provides more information, its cost, limited availability, restricted patient access, and other contraindications such as patient claustrophobia or metal implants limit its use

A 23-year-old man is involved in an altercation in the parking lot after a baseball game. He suffers a single stab wound 2-cm medial and superior to the left nipple. His blood pressure is 110/80 mm Hg and heart rate is 80 beats per minute. Which of the following management options is most appropriate for this patient? A. CXR, wound exploration, and ECG B. CXR and CT scan of the abdomen C. CXR and echocardiography D. CXR, echocardiography, and laparoscopy

C. CXR is sensitive in identifying hemothorax and pneumothorax, while echocardiography is useful in identifying pericardial fluid. Wound exploration of the chest wound is not recommended because the information gained is limited and the procedure is associated with the potential of producing pneumothorax. An ECG provides limited information regarding cardiac injury and is generally not done. A stab wound above the nipple line is rarely associated with intra-abdominal injury, therefore, CT scan of the abdomen or diagnostic laparoscopy is unnecessary.

A 67-year-old woman is seen in the emergency room with left arm weakness and right facial droop. Her blood pressure is 180/105 mm Hg. Which of the following is the best management for the hypertension? A. Lower the blood pressure to less than 160/80 mm Hg by giving a small dose of labetalol. B. Lower the blood pressure to less than 120/80 mm Hg. C. No intervention for her blood pressure, but continue to monitor. D. Lower the blood pressure to below 160/80 mm Hg if she is eligible for tPA

C. Emergency administration of antihypertensive agents should be withheld in acute stroke to maintain cerebral perfusion pressure, unless the blood pressure is greater than 220/120 mm Hg. Patients are eligible for tPA with BP < 185/110 mm Hg. If patients have concurrent conditions that require acute lowering of blood pressure such as aortic dissection, hypertensive encephalopathy, acute renal failure, or congestive heart failure, a reasonable goal is to lower their mean arterial pressure 15% to 25% within the first 24 hours.

An 18-year-old woman is brought to the ED with suspected anaphylaxis. Which of the following most suggests anaphylaxis rather than a simple allergic reaction? A. Itching B. Watery eyes C. Blood pressure of 80/40 mm Hg D. Hives E. Anxiety

C. Hypotension indicates a systemic reaction and cardiovascular compromise, thereby classifying this allergic reaction as anaphylaxis. The other option may all be part of an anaphylactic response, but may also just be simple allergic reactions.

A 37-year-old man is brought into the ED because he passed out at work. He denies any prodromal symptoms. Family history is negative for sudden cardiac death. In the ED, his BP lying down is 125/75 mm Hg, heart rate is 75 beats per minute, and respiratory rate is 14 breaths per minute. The patient's blood pressure and heart rate standing are 120/75 mm Hg and 77 beats per minute, respectively. His ECG shows a sinus rhythm with a rate of 72. Physical examination does not reveal any abnormal findings. Currently, he is lucid and has no neurologic abnormalities. After a complete evaluation of this patient, which of the following is the most common etiology of syncope? A. Dysrhythmia B. Orthostasis C. Idiopathic D. Situational

C. Idiopathic. Approximately 50% of all patients with a presenting complaint of syncope will not have a definitive cause. Cardiac causes of syncope (eg, dysrhythmia) are the most worrisome, because patients are at increased risk for sudden cardiac death. Situational syncope is a rare cause of syncope. It is a result of an abnormal autonomic reflex response to a physical stimulus. Some triggers of this response include coughing, swallowing, defecation, and micturition. The patient does not have evidence for orthostatic hypotension as demonstrated by his vital signs.

A 35-year-old woman presents to the ED complaining of feeling light-headedness. She noticed some vaginal bleeding earlier in the day. Her blood pressure is 85/53 mm Hg, heart rate is 130 beats per minute, and respiratory rate is 18 breaths per minute. Which of the following is the most appropriate next step in management? A. Obtain a urine pregnancy test. B. Obtain a serum quantitative beta human chorionic gonadotropin (-hCG). C. Obtain immediate IV access and begin fluid resuscitation. D. Obtain stat OB/GYN consult.

C. Obtain IV access and begin fluid resuscitation. Investigating the possibility of pregnancy, specifically ectopic pregnancy, is critical. However, initial stabilization of the patient takes precedence. Hypotension must be treated emergently with fluids. Obtaining a consult early in the patient's course is important. Definitive management will be in the operating room.

A 72-year-old man is brought to the ED by paramedics after passing out at the supermarket. His syncopal episode was witnessed by shoppers who stated the patient collapsed, hitting his head. The patient is currently alert and oriented, and denies any persistent symptoms. His past medical history is significant for carotid stenosis, for which he takes aspirin and clopidogrel. What is most appropriate next step in the management of this patient? A. Head CT scan B. Order a carotid duplex ultrasound C. Obtain an ECG D. Chest radiograph

C. Obtain an ECG. This patient has a high probability for a cardiac cause of his syncope. Initial management includes placing the patient on a cardiac monitor and obtaining an ECG to monitor for dysrhythmias. A head CT scan should be performed after an ECG is obtained. A carotid duplex ultrasound and chest radiograph may aid in the workup for syncope, but it is most important to first rule out a dysrhythmia.

An 18-year-old man presents to the emergency department complaining of right ear pain after sustaining a cut on his ear during a wrestling match. On examination, you note some swelling and exposed cartilage of the right upper ear. Which of the following is a correct statement? A. Exposed cartilage should be left undressed and the patient should be discharged with follow-up. B. Hemostasis and evacuation of an auricular hematoma should not be performed because it promotes infection. C. When repairing an ear laceration, make sure to avoid placing sutures in the cartilage and only include the perichondrium when approximating the skin edges. D. Tetanus toxoid is not recommended for these types of injuries

C. Small superficial ear lacerations should be repaired with uninterrupted sutures. Do not place sutures in lacerated ear cartilage. Sutures placed in the skin surrounding these wounds in the cartilage should include the perichondrium (thin tissue layer overlying the cartilage). This method allows the approximation at the cartilage edges. Exposed cartilage should be covered or dressed to prevent infection and necrosis. Hemostasis and evacuation of an auricular hematoma is recommended to prevent the development of "cauliflower ear." All patients with interruptions in the skin should be offered tetanus prophylaxis if their immunization status is not current

Which of the following patient's presentation is most compatible with the Brown-Sequard syndrome? A. A 20-year-old man with absence of all motor/sensory functions in all extremities B. A 20-year-old man with greater weakness in the upper extremities than the lower extremities C. A 20-year-old man with complete motor paralysis, loss of vibratory sensation and proprioception on the ipsilateral side, and contralateral loss of pain and temperature sensation. D. A 20-year-old man with fracture/dislocation of C5-C6 and intact motor/sensory functions throughout E. A 20-year-old man with normal CT of the C-spine and motor and sensory deficits below the C6 level

C. The Brown-Sequard syndrome is caused by posterior spinal cord injury, characterized by paralysis, loss of vibratory sensation and proprioception on the ipsilateral side, and loss of pain and temperature sensation on the contralateral side. Patient described in A is compatible with complete cord injury. The patient described in B is compatible with central cord injury. The patient in D appears to have vertebral fractures/dislocation without neurologic compromises. The patient in E has a spinal cord injury without radiographic abnormality (SCIWORA); SCIWORAs occur more commonly in children than adults.

A 34-year-old man is brought into the emergency department after a motor vehicle accident. He complains of dyspnea and initially had an oxygen saturation of 88%. On examination, he has decreased breath sounds of the right chest and now has an oxygen saturation of 70% on room air. Which of the following is the most appropriate next step? A. Chest radiograph B. CT of the chest C. Tube thoracostomy D. Heparin anticoagulation

C. The constellation of clinical signs points toward a pneumothorax. The presence of significant hypoxia requires immediate placement of a chest tube prior to chest radiograph confirmation as further delay may progress to cardiovascular collapse.

A 66-year-old woman is noted to have acute pneumococcal pneumonia and is being treated with antibiotics, and with norepinephrine and dobutamine to maintain her BP and urine output. Which of the following is a bad prognostic sign? A. Urine output of 1 mL/kg/h B. Mean arterial blood pressure of 80 mm Hg C. Lactic acid level of 6 mmol/dL D. Serum bicarbonate level of 22 mEq/L E. Hematocrit 35%

C. The elevated serum lactate is evidence that oxygen supply is not meeting systemic oxygen demand. A lactate level 4 is a poor prognostic sign. The other parameters are normal.

Which of the following initial ventilator settings is appropriate for intubated asthmatics? A. IMV mode, rate 16, tidal volume 6 to 8 mL/kg B. IMV mode, rate 16, tidal volume 10 to 12 mL/kg C. AC mode, rate 8 to 10, tidal volume 6 to 8 mL/kg D. AC mode, rate 8 to 10, tidal volume 10 to 12 mL/kg E. AC mode, rate 16, tidal volume 6 to 8 mL/kg

C. The initial settings for patients with obstructive lung disease should be AC mode, rate 8 to 10, tidal volume 6 to 8 mL/kg. Low volumes and small tidal volumes are used to prevent air stacking and barotrauma.

A 24-year-old woman was the victim of domestic violence and received treatment at the local emergency department for multiple contusions and lacerations of the face. Six months after treatment, she notices a defect of the nasal septum with communication between the right and left nasal passage way. Which of the following is the most likely diagnosis? A. Physician use of epinephrine on the nasal septum B. Patient use of cocaine C. Hematoma of the nasal septum D. Post-traumatic stress syndrome

C. The patient likely developed a septal hematoma, which caused necrosis to the septum and the subsequent communication between the nasal passageways. Cocaine is associated with septal perforation secondary to its vasoconstrictive properties. There is no indication that this patient used cocaine. The use of epinephrine on the nose is contraindicated because of the potential for necrosis. However, epinephrine is not associated with septal perforation. Although post-traumatic stress syndrome can be debilitating for patients, it does not cause septal perforation.

A 24-year-old man is brought into the ED complaining of an exacerbation of his asthma. Which of the following is the most appropriate method of assessing the severity of his disease? A. Spirometry B. Measurement of the diffusion capacity of the lungs C. Measurement of the peak expiratory flow D. Measurement of the alveoli oxygen tension

C. The peak expiratory flow is a reliable and fairly accurate method of assessing asthma severity. Spirometry, although providing important information, is rarely available in the ED.

A 17-year-old adolescent boy who is a type I diabetic is brought in by his parents with concern about diabetic ketoacidosis. He has had several prior episodes of DKA. Which of the following is most diagnostic of DKA? A. Polyuria, polydipsia, fatigue B. Hypotension, dehydration, fruity breath odor C. Hyperglycemia, ketosis, metabolic acidosis D. Serum blood sugar of 600 mg/dL in the face of high concentrations of insulin E. Elevated HCO3 and elevated glucose

C. The triad of hyperglycemia, ketosis, and acidosis is diagnostic of DKA. Many other conditions cause one or two of the triad, but not all three. Although a fruity breath odor may suggest acetone, it is not reliably present and not all clinicians can distinguish it.

Your dog, who was immunized against rabies within the last year, bites your neighbor. A. Identify the species, clean and immobilize the site, and administer antivenin. B. Clean bite site and treat with prophylactic antibiotics. C. Clean site, observe animal, and watch for signs of secondary infection. D. Clean the site and begin rabies prophylaxis with active and passive immunization. E. Admit for radical surgical debridement in the operating room

C. This is a low-risk bite. The dog is your housedog with a low risk of ever contracting rabies. You have it immunized every year and can observe it for 10 days. As always, clean the bite thoroughly and consider radiographs to be sure no broken teeth are in the wound or that the bone has been penetrated. Administer tetanus if indicated and watch for secondary bacterial infection. Prophylactic antibiotics are indicated.

A 54-year-old woman presents to the ED requesting medication refills on her antihypertensive medications. She has been out of her medications for 2 weeks and cannot get an appointment with her private physician until next week. She normally takes atenolol and hydrochlorothiazide. Her blood pressure is 190/100 mm Hg. The patient has no complaints. She has been waiting for 4 hours and is in a hurry to get back to work. Which of the following is the most appropriate next step? A. Change her medications to a calcium channel blocker. B. Admit to the intensive care unit and initiate intravenous nitroprusside. C. Give her a prescription for her medications, instruct her to take them immediately, and have her follow-up in 48 hours. D. Counsel the patient on the dangers of her noncompliance, admit to the hospital, and begin the patient on intravenous labetalol

C. This patient has hypertensive urgency. She has no symptoms related to her elevated blood pressure and no signs of end-organ damage. The patient should restart her medications and have her blood pressure reassessed in 48 hours.

Which of the following is the most appropriate next step in the management of a 22-year-old man with C5 fracture and C5-C6 subluxation, absence of motor or sensory functions below the C4 level, heart rate of 45, and BP 100/60? A. Maintain mean arterial pressure >85 to 90 mm Hg B. Surgical airway C. Orotracheal intubation with rapid sequence induction D. Blind nasotracheal intubation E. Administer atropine 1mg intravenously

C. This patient has signs consistent with neurogenic shock following a high spinal cord injury. The first concerns are his airway and ventilation. The airway appears to be clear but he needs a definitive airway to maintain optimal ventilation. Orotracheal intubation with rapid sequence induction and in-line C-spine stabilization is the optimal airway strategy for this patient. Maintenance of adequate pulse and blood pressure are important to maintain spinal cord perfusion, but these steps should be delayed until a secured airway is established.

Which of the following management options is the greatest determinant of patient outcome in anaphylaxis? A. Timely administration of steroids B. Administration of diphenhydramine C. Early identification of the allergen D. Early administration of epinephrine E. Aggressive resuscitation with intravenous fluids

D. Again, early recognition of anaphylaxis and immediate dosing of epinephrine is most important.

A 32-year-old man was involved in a knife fight and had stab injuries to his abdomen, although it is unclear how deep these injuries are. He is brought into the emergency room with a heart rate of 110 beats per minute and blood pressure of 84/50 mm Hg. Based on the clinical assessment, which of the following is the amount of acute blood loss he has experienced? A. 250 mL B. 500 mL C. 1000 mL D. 1500 mL

D. Blood pressure at rest typically does not decrease until class III hemorrhagic shock, when 1500 to 2000 mL of blood is lost (30%-40% of blood volume). Class I hemorrhagic shock is well compensated associated with 750 mL EBL or less, with no effect on blood pressure and minimal effect on heart rate. Class II shock, associated with 750 to 1500 mL EBL, is associated with tachycardia but normal blood pressure at rest, and low urine output.

For which of the following patients is CT imaging an appropriate diagnostic option? A. A 38-year-old man with diffuse abdominal pain, involuntary guarding, and a 6-in knife impaled just below the umbilicus B. A 22-year-old man with a single stab wound to the back, pulse rate of 118 beats per minute, blood pressure of 94/80 mm Hg, and gross hematuria C. A 16-year-old adolescent boy with a single stab wound 2 cm above the left inguinal crease, with heart rate of 120 beats per minute and blood pressure of 90/78 mm Hg D. A hemodynamically stable, 34-year-old woman, who is 26 weeks pregnant and has a single stab wound to the back and no other abnormalities on physical examination

D. CT of the abdomen may be useful in identifying injuries to the retroperitoneal structures in a patient with a stab wound to the back. That the patient is 26-week pregnant does not contraindicate CT scan. Further diagnostic study would not be beneficial in patients listed in choices A, B, and C because these patients are exhibiting signs of significant injury that would necessitate urgent exploratory laparotomy.

A 52-year-old healthy man presents with a 3-day history of a pleuritic chest pain and SOB. He has normal vital signs and physical examination. Which test is most useful in ruling out this patient for pulmonary emboli? A. Electrocardiogram (ECG) B. Chest x-ray C. Arterial blood gas (ABG) D. D-dimer level E. Oxygen saturation

D. ECG findings are often normal or nonspecific in patients with PE. ST-segment and T-wave abnormalities are the most common, but occasionally signs of right-heart stain may be noted, including peaked P waves in lead II (P pulmonale), right-bundle-branch block, supraventricular arrhythmias, and right-axis deviation. The classic ECG findings of PE are S wave in lead I, Q wave in lead III, and inverted T wave in lead III (S1Q3T3); however, this is rarely seen. ECGs may help to diagnose other etiologies of chest pain and shortness of breath such as pericarditis or tachydysrhythmias. Chest radiographs are also usually normal. In severe PE, dilation of proximal pulmonary vessels with collapse of distal vasculature is noted (Westermark sign). Twenty-four to seventy-two hours after a PE, atelectasis and a focal infiltrate may be seen as a consequence of loss of surfactant. Pleural effusions may be noted, and, rarely, a triangular or rounded pleural-based infiltrate with its apex pointed to the hilum (Hampton hump) may be seen in the case of an infarction. ABG findings are often confusing, and abnormalities are usually a result of underlying pathology such as chronic obstructive pulmonary disease (COPD) or pneumonia. A low PO2 in an otherwise healthy patient at risk for DVT/PE is more useful. O2 saturation is rarely depressed and not very useful in the workup of PE. High sensitivity D-dimer levels are most useful for their negative predictive value in helping to rule out PE in low to moderate pretest-probability patients. It is a very sensitive, but nonspecific test. A normal high sensitivity D-dimer level in a low to moderate pretest probability patient makes PE unlikely and further diagnostic workup is not indicated.

A 5-year-old boy is brought to the ED by his mom for a forehead laceration after hitting his head on the jungle gym. There was no loss of consciousness. The child is alert and active. He has a 3-cm forehead laceration which crosses the hairline. Which of the following is the most appropriate method of wound closure in this patient? A. Shave the hair surrounding the laceration and close with interrupted sutures. B. Close with staples. C. Close with steri-strips. D. Close with interrupted sutures

D. Facial lacerations should be closed with a 6-0 nonabsorbable suture in interrupted fashion. Staples do not provide the desired cosmesis for a facial wound repair. Staples are more appropriate for scalp lacerations. Steri-strips can be used in very small skin openings with minimal tension. They will not provide the tensile strength required for this patient's wound closure. Shaving surrounding hair increases the risk of infection and is not recommended.

A 28-year-old insulin-requiring woman is found in her apartment by her husband. She is stuporous and cannot provide any history. EMS is called and takes the patient to the emergency center, and a diagnosis of severe DKA is made. Her blood pressure is 80/40 mm Hg and heart rate 140 beats per minute. The glucose level is 950 mg/dL, potassium level 6 mEq/L, HCO3 4 mEq/L. Which of the following is the most appropriate initial treatment? A. Administer 20 units regular insulin intramuscularly, and normal saline at 250 mL/h. B. Begin an intravenous dopamine drip to raise BP above 90, then insulin at 10 U/h. C. Initiate normal saline 2 L with KCl 20 mEq/L, insulin 10 U/h. D. Provide an intravenous normal saline 2 L bolus, and start an insulin drip at 10 U/h.

D. Fluid resuscitation via isotonic crystalloid solution to reverse shock, and IV insulin to reverse ketoacidosis, are the mainstays of therapy. Though most patients will require potassium, it should not be given while the serum K is elevated, and typically not until urine output is seen. Pressors have a limited role until the intravascular volume is restored.

A 78-year-old man is brought to the emergency center from an extended care facility. The patient reportedly was found to have fallen down in the bath room. He has contusions over his face and is confused. According to reports by his caretakers, this is his baseline mental status. How would you clear his C-spine? A. Palpation of his C-spine for tenderness, if not tender than ask him to turn his head and if no pain is reported, the C-spine is cleared. B. Keep him in C-spine precaution and reexamine him later when his mental status is improved. C. Obtain CT, MRI, if these are negative, obtain flexion/extension films. D. CT of the C-spine. E. Remove the collar if he denies neck pain.

D. For this patient with chronic altered mental status due to underlying medical conditions; therefore, the approach to clear his C-spine is one directed toward obtunded patients. His C-spine can be cleared based on a normal CT of the C-spine alone, which is sufficient to identify greater than 99% of all vertebral bony fractures/dislocations. An MRI can be added to identify the rare instances of isolated ligamentous injuries if the CT is normal. There is no consensus on whether MRI is indicated in this setting.

A 6-year-old girl with a known peanut allergy is brought to the ED by ambulance after accidentally eating a cookie made with peanut butter at a school party. She is wheezing with hives. Which of the following should be the first intervention? A. Endotracheal intubation B. Normal saline 20 cc/kg IV C. Examination of the skin D. Epinephrine 0.15 mg intramuscular E. Nebulized albuterol

D. Intramuscular epinephrine should be administered immediately. If there is significant respiratory or airway compromise, then the patient should be controlled.

A 35-year-old man has been involved in a motor vehicle accident, and is found to be hypotensive. Which of the following locations of bleeding can cause significant complications but does not explain the hypotension? A. Chest and abdomen B. Pelvic girdle and soft-tissue compartments C. External bleeding D. Intracranial bleeding

D. It is important to systematically check for bleeding sources in the chest, abdomen, pelvic girdle, soft-tissue compartments (long-bone fractures), and external bleeding. Intracranial bleeding, although a significant injury, is usually not the cause of hypotension. The exception to this is the patient who is moribund secondary to a head injury.

A 21-year-old man is brought to the ED after collapsing to the ground while playing basketball. He is alert and oriented, denies chest pain, difficulty breathing, or any other physical complaints. There was no trauma. He denies any past medical problems. Physical examination is unremarkable. Which of the following elements on his ECG is concerning for a life-threatening cause of syncope? A. Heart rate of 55 B. P-wave inversion in lead aVR C. Sinus arrhythmia D. QTc of 495 msec

D. The upper level of normal for the corrected QT interval is approximately 440 msec for men and 460 msec for women. A finding of a prolonged QT interval should prompt a more thorough investigation into this patient's medications, family history, and potential electrolyte imbalances. Prolonged QT syndrome is associated with sudden death, especially in young athletes. Mild bradycardia alone in a young, healthy patient who has fully recovered from an episode of syncope is of little concern. P-wave inversion in lead aVR is a normal finding. Sinus arrhythmia is a normal variation in the RR interval with respiration.

While raking leaves under his fruit tree at dusk, a man says a bird flew into his face. When he checked his face in the mirror he saw a bite mark under blood streaks. A. Identify the species, clean and immobilize the site, and administer antivenin. B. Clean bite site and treat with prophylactic antibiotics. C. Clean site, observe animal, and watch for signs of secondary infection. D. Clean the site and begin rabies prophylaxis with active and passive immunization. E. Admit for radical surgical debridement in the operating room

D. This injury is at high risk for rabies transmission. Dusk is the usual time for bat activity, and although this man did not feel a bite, he discovered bite marks under his injury site. Bats carry high rates of rabies and this man was bitten on the face. Because the animal cannot be examined, immediate passive and active immunization should be initiated and tetanus administered, if indicated. As always, watch for secondary bacterial infection and update his tetanus status if it has been more than 5 years since his last immunization.

A 45-year-old man with acute cholecystitis is noted to have a fever of 38.3°C (101°F), hypotension, and altered sensorium. His HCT is noted to be 24%. Broad-spectrum antibiotics and intravenous saline are administered, and, although his CVP is 10 and his MAP is 80, his ScvO2 remains <70%. Which of the following is most likely to be beneficial? A. Initiate corticosteroids B. Tight glucose control C. Acetaminophen 500 mg PR D. Transfusion E. Lithotripsy

D. This patient has met two of the three goals of EGDT, but fails to meet the third goal of ScvO2 >70%. In the setting of HCT <30%, transfusion with PRBCs is indicated. Tight glucose control and steroids have not been shown to consistently improve mortality in all comers with severe sepsis.

A 57-year-old man presents to the ED complaining of shortness of breath. The onset was sudden, and is associated with pleuritic chest pain. He was recently released from the hospital after being diagnosed with lymphoma. He had an indwelling catheter placed in his left subclavian vein the day before for chemotherapy administration. He was previously healthy without significant medical history. His vital signs are heart rate of 105 beats per minute, blood pressure 126/86 mm Hg, respiratory rate of 28 breaths per minute, O2 saturation 100% on room air. The breath sounds are clear bilaterally. His heart sounds are normal without an S3 or S4 gallop. His left arm is mildly edematous, but otherwise painless, with a normal pulse examination. There is no swelling of his lower extremities and he has no pain with palpation of his calves. His catheter incision site is clean and intact. Which of the following studies is inappropriate for this patient? A. Chest x-ray B. ECG C. Contrast CT scan of the chest D. D-dimer assay E. Duplex ultrasonography of the deep veins of the upper and lower extremities

D. This patient may very well have a PE, but other sources of his chest pain and shortness of breath must also be considered. An ECG will aid in the diagnosis of cardiac etiologies including heart attacks or arrhythmias. A chest x-ray will show other possible pulmonary processes, including pneumonia or a pneumothorax from the central line placement (as well as confirm the position of the line). Duplex ultrasonography will help examine the venous system for thromboses and possible sources of PE, including the deep veins of the upper extremity, because this patient now has an indwelling catheter that can be a source of thrombus formation. A D-dimer assay is not useful in this patient because he is a high-probability patient and this test should only be ordered in low-probability patients. CTA would be an appropriate test to order in this patient as it can diagnose a PE as well as other etiologies of his symptoms. Also, pulmonary angiography is not yet indicated in this patient until further diagnostic workup leads one to suspect a PE as the source of his symptoms with an otherwise negative workup. Pulmonary angiography is invasive, costly, time consuming, and not without its own complications, and should therefore be used judiciously.

Hyperglycemia, ketosis, and acidosis confirm the diagnosis of ? and are enough to start fluids and insulin.

DKA

Most morbidity in ? is iatrogenic

DKA

A 19-year-old woman is admitted to the hospital for an exacerbation of asthma likely precipitated by pollen and colder weather. Her inpatient regimen includes both intravenous and inhalant medications. Which of the following medications is most likely to be used as part of discharge plan? A. Theophylline B. Antibiotics C. Magnesium D. Histamines E. Corticosteroids

E. Corticosteroids are often used after a hospitalization. Other standard medications include beta-agonists and oral leukotriene antagonists. None of the other medications are used routinely for discharged asthma patients.

An 18-year-old man was involved in an altercation at a local bar. He suffered a laceration of the scalp, neck, forehead, and upper lip. Which of the following is likely to be most challenging to repair from a cosmetic perspective? A. Scalp B. Neck C. Forehead D. Cheek E. Upper lip

E. Lining up the vermillion border is by far the most challenging to repair because even a 1-mm discrepancy is noticeable. Injuries to the scalp usually can be repaired with sutures or staples, and are rarely cosmetically debilitating. Injuries to the neck, forehead, and cheek require approximation of wound edges to ensure appropriate wound healing; however, these lacerations do not require meticulous approximation as seen in repair of the vermillion boarder. It is important to point out to your patients that all laceration repairs will leave a scar.

The physician explains to a 25-year-old man who has recently been hospitalized with DKA that patients in DKA often have other illnesses or precipitating factors that initiated the ketoacidosis. Which of the following is the most common underlying etiology in DKA? A. Asthmatic exacerbation B. Cocaine use C. Cholecystititis D. Missed insulin doses E. Urinary tract infection

E. Many serious illnesses can precipitate an episode of DKA in the susceptible patient, including infection, stroke, myocardial infarction, pancreatitis, trauma, and surgery. Associated or precipitating illness should always be sought diligently. Urinary tract infection is the single most common underlying cause. Missed insulin doses are also common, but less common than infection.

A 32-year-old man collapses in the emergency room after being brought in by paramedics. He was stung by a bee and known to be highly allergic. He appears cyanotic and had extreme stridor in the ambulance. Severe laryngeal edema is notable. Which of the following is the best treatment? A. Nebulized albuterol, H1 and H2 antagonists, corticosteroids, and crystalloids B. Subcutaneous epinephrine, H1 and H2 antagonists, and corticosteroids C. Rapid sequence intubation, subcutaneous epinephrine, and corticosteroids D. Intramuscular epinephrine, rapid sequence intubation, and corticosteroids E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists

E. This patient has severe anaphylaxis, and it would be appropriate to move straight to intravenous epinephrine. If intravenous dosing is not immediately available, then intramuscular epinephrine should be given. Attention should then be turned to managing the airway. Because of the significant laryngeal edema, endotracheal intubation will be nearly impossible; hence, cricothyroidotomy may be required. After securing the airway, steroids, beta agonists, H1 and H2 antagonists should be administered.

? should be administered early for asthmatic exacerbations and continued for at least 1 week.

Glucocorticosteroids

? is an acute disease of wound contamination, which is largely preventable with immunization

Tetanus

Initiate therapy with ? while obtaining history and performing a physical examination for patients with significant asthma.

albuterol

Steroids, antihistamines, and beta agonists are all helpful pharmacologic adjuvants for managing the many symptoms of ?

anaphylaxis

The Canadian C-spine rule is an effective evaluation system to clinically clear C-spines in ? patients

asymptomatic

Cervical spine injuries occur in 1% to 3% of all victims following ? trauma.

blunt

An early and thorough search for a source must be undertaken, with immediate measures taken to control it. Whether or not an operable source is found, ? should be started immediately. If an operable source is found, it should be surgically treated as soon as the patient can tolerate it.

broad-spectrum antibiotics

Most asthmatics should be discharged from the ED with inhaled ? for ongoing preventative therapy

corticosteroids

Patients in DKA are almost always ? and have significant sodium and potassium deficits, regardless of their specific laboratory values.

dehydrated

Hypertensive emergency is defined as markedly elevated blood pressure in the presence of ?

end-organ damage

High-sensitive D-dimer study is useful for its negative predictive value in ? DVT and PE.

excluding

The ? nerve courses from the mastoid region across the cheek area and is prone to injury in facial lacerations

facial

Initially, large volumes of ? administered in multiple boluses may be necessary (and in some cases sufficient) to maintain perfusion.

fluid for sepsis

Hypotension in a trauma patient is ? until proven otherwise

hemorrhage

Eighty percent of PEs develop from DVTs involving the ?, ?, and ? veins

iliac, femoral, or popliteal veins.

One of the most common reasons for hypertensive emergency is patient ?

noncompliance with antihypertensive medication.

Measure ? to help assess asthma severity and monitor progression during treatment.

peak flow

In the United States, ? transmission by dogs is nearly zero whereas transmission by bats is more often seen. Worldwide, dog transmission is still common.

rabies

Distal ? fractures have a bimodal pattern with peaks in late childhood and after the sixth decade of life.

radius

Early goal-directed therapy for ? includes careful monitoring of multiple markers of organ perfusion, with aggressive measures to restore any imbalance between oxygen supply and demand.

sepsis

Older, younger, or immunocompromised individuals may present with subtle signs such as lethargy, decreased appetite, or hypothermia.

severe sepsis

A bedside glucose measurement and a CT scan of the head are the most urgent diagnostic studies in suspected ?.

stroke

The most common causes of severe sepsis are ? and ?

urosepsis and pneumonia.

A ? agent such as ? or dopamine is the next step in treating hypotension that persists despite intravenous fluids for sepsis.

vasopressor, norepinephrine

The ? border must be precisely approximated because of its important cosmetic characteristics. Even a small discrepancy in lining up of the tissue is noticeable.

vermillion