Emergency Care

A 24-year-old woman presents to the emergency department after a high-speed motor vehicle collision. Her GCS is 14. On neurological examination, she has intact fine touch, and loss of pain, strength, and temperature sensation below the T10 level. What is the most likely diagnosis? A. Anterior cord syndrome B. Brown-Sequard syndrome C. Cauda equina syndrome D. Central cord syndrome

A Injury to the anterior two-thirds of the spinal column results in anterior cord syndrome which is characterized by bilateral loss of motor function and pain and temperature sensation below the level of injury. The dorsal column is usually spared so vibration sense and proprioception are preserved. Anterior cord syndrome carries the worst prognosis of all the incomplete spinal cord syndromes, with less than 20% regaining any degree of muscle function.

A 2-year-old girl presents to the ED after a possible ingestion. She was accompanied by her grandparents who found her with an opened bottle of pills. There were two pills found in her mouth although the caretakers are not certain as to how many pills are missing. In transit to the ED, the girl was asymptomatic. Your examination at the ED reveals an alert girl with bradycardia, hypotension, normal pupillary size and reaction. You perform an ECG that shows sinus bradycardia. Blood glucose is normal. Which of the following medications could the girl most likely have ingested? A. Clonidine B. Metoprolol C. Nortriptyline D. Phenobarbital

B Beta blocker toxicity results in decreased chronotropy and inotropy in addition to slowing conduction through AV nodal tissue. These effects are manifested as bradycardia, hypotension, and heart block. Blood glucose should be measured in all patients as hypoglycemia may be seen. Treatment involves supportive care and gastrointestinal decontamination as indicated. Glucagon and high-dose insulin are the the antidotes of choice for beta-blocker toxicity.

What is the most common pathogen found in dog bite wounds that should be taken into consideration when treating for infection? A. Eikenella B. Pasteurella C. Staphylococcus species D. Streptococcus species

B The predominant pathogen in dog bite injuries is Pasteurella and the choice of antibiotic should take this organism into consideration. Antibiotic prophylaxis is generally recommended for the following types of wounds: deep puncture wounds, moderate to severe wounds with crush injury, wounds in areas with underlying venous and lymphatic compromise, wounds on the hand, genitalia, or close to a bone, wounds requiring closure, and wounds in immunocompromised hosts Use amoxicillin-clavulanate, or if PCN allergy, use a FQ + clindamycin or metronidazole or trimethoprim/sulfamethoxazole plus clindamycin or metronidazole can be prescribed.

A 2-year-old girl is brought to the emergency room after she was found with an open bottle of her grandfather's pills. Mom states she had a couple episodes of vomiting before arrival. In the emergency room, she is tachypneic, febrile, and diaphoretic. Laboratory results reveal sodium 140, potassium 4.0, chloride 100, and bicarbonate 12. A venous blood gas shows pH 7.29, pCO2 22, and pO2 89. Which of the following is indicated in the management of this patient? A. Flumazenil B. N-acetylcystein C. Naloxone D. Sodium bicarbonate

D This patient presents with a mixed acid-base disorder due to salicylate toxicity from aspirin. Her labs are consistent with a metabolic acidosis and respiratory alkalosis. Presenting symptoms include tachypnea as the patient tries to compensate for the metabolic acidosis. Vomiting, diarrhea, fever, tinnitus, vertigo, diaphoresis, lethargy, and coma are also possible. Management is supportive, as with most toxicities, and should include alkalinizing the urine with sodium bicarbonate to aid in renal excretion. Severe cases may require dialysis. Flumazenil (A) can be administered for benzodiazepine overdose. Naloxone (C) is indicated for respiratory depression or decreased consciousness associated with opiate overdose. N-acetylcysteine (B) is given in acetaminophen toxicity to prevent liver failure

A 23-year-old man presents after closing his right hand in a car door. He is complaining of 10/10 sharp pain to his right index finger. On examination, you note the distal phalanx of the right index finger has ulnar deviation. It is edematous and ecchymotic. The fingernail is intact, however, a subungual hematoma occupying approximately 25% of the nail is present. What is the first step in the management of the subungual hematoma? A. Application of ice to the index finger B. Splinting of the right index finger C. Trephination of the fingernail D. X-ray of the right index finger

D Trephination of the fingernail will relieve the pain associated with this condition and is not contraindicated if there is a suspected fracture of the distal phalanx. It is contraindicated if there is suspected subungual melanoma or if the nail is crushed or fractured. Because of the patient's history of a crush injury and clinically observed ulnar deviation of the distal phalanx, an X-ray of the right index finger is the first step in the management of this subungual hematoma.

A 21-year-old man presents with a facial injury that occurred just prior to his arrival. He was struck in the left eye by a baseball. He is complaining of pain in the left side of his face and nasal area. Visual acuity is 20/20. Physical exam reveals mild left periorbital swelling and bruising and decreased sensation over the left maxillary area. Slit lamp exam reveals a clear anterior chamber. CT scan reveals orbital air. What is the most likely diagnosis? A. Ethmoid bone fracture B. Hyphema C. Retrobulbar hematoma D. Traumatic lens dislocation

A An ethmoid bone fracture is a fracture of part of the medial wall of the orbit and can occur with blunt force trauma to the periorbital area. Patients will complain of swelling in the periorbital area and facial pain. They may have minimal bruising in the eyelids; however, they may complain of swelling that worsens when they blow the nose. This is due to the collection of subcutaneous emphysema from the communication between the ethmoid sinus and the orbit.

A five-year-old boy is playing with his two-year-old sister when he calls to tell his mother that the girl put a dime in her mouth. The mother could not find anything in the girl's mouth so she brings her to the emergency department. Your physical examination is normal. Which of the following is the next best step? A. Obtain X-ray of the neck, chest, and abdomen B. Order barium contrast studies C. Provide reassurance to the mother D. Request for urgent endoscopy

A Coins and small toy items are the most commonly ingested foreign bodies. There may be symptoms of choking, gagging, and coughing that may be followed by excessive salivation, dysphagia, food refusal, emesis, or pain in the neck, throat, or sternal notch regions. The evaluation of a child with a history of foreign body ingestion should begin with plain anteroposterior (AP) radiographs of the neck, chest, and abdomen, along with lateral views of the neck and chest. Requesting an urgent endoscopy may be the next step after plain films are obtained. Urgent endoscopy is not needed if plain films fail to visualize the object and the patient remains asymptomatic.

What is the most common pathogen found in infected cat bites? A. Bartonella henselae B. Pasteurella multocida C. Staphylococcus aureus D. Streptococcus pyogenes

B Cats have narrower, smaller teeth, resulting in most bites being deep puncture wounds. Cat bites are also more likely to be found on the hands which increases the risk of infection as well. The most common pathogen found in infected cat bites is Pasteurella multocida, a virulent facultatively anaerobic gram negative rod. Infection from Pasteurella typically occurs within 24 hours (earlier than cellulitis due to other pathogens) with erythema, warmth, swelling, and pain on examination. Purulent drainage is often seen as well. Prophylaxis with a 3-5 day course of amoxicillin-clavulanate

A 2-year-old girl presents to the emergency department at 6 pm with bloody vomiting, diarrhea and abdominal pain. Her pregnant mother reports that the patient's grandfather was watching the patient in the afternoon while the mother was shopping. The mother returned home at around 5pm to find her daughter vomiting and with diarrhea and abdominal pain. An abdominal X-ray shows radiopaque particles in the stomach. After fluid resuscitation, what is the next best step in management? A. Bowel irrigation with polyethylene glycol B. Deferoxamine administration C. Ipecac-induced emesis D. N-acetylcysteine administration

B Deferoxamine is a chelating agent that binds iron and is indicated for persistent gastrointestinal symptoms, if pills are visible on radiographs, if the serum iron level is greater than 500 µg/dL, or if an estimated dose greater than 60 mg/kg of elemental iron was ingested. Iron tablets tend to look like candy

An 18-year-old man is found to have a tibia fracture after he was struck by a motor vehicle while crossing the road. An X-ray of his leg is showing two separate transverse fractures in this tibia with a section of the tibia in the middle. What is the orientation of this fracture? A. Comminuted B. Greenstick C. Segmental D. Spiral

C A single, large, free-floating segment of tibia bone between two well-defined fracture lines is a segmental fracture. In addition to orientation, fractures should also be described in terms of whether the fracture is open or closed, the location of the fracture in the shaft, displacement and separation, and angulation. Tibia fractures are often open injuries because of the minimal amount of subcutaneous tissue between the fracture and the skin. Open fractures require immediate orthopedic consult and administration of IV antibiotics along with appropriate analgesia and splinting.

Which of the following patients is most likely to sustain a Chance fracture in a motor vehicle collision? A. A 19 year old unrestrained passenger B. A 2 year old in a rear-facing seat with a five point harness C. A 32 year old pregnant passenger wearing a lap belt D. A 40 year old driver wearing a three point belt

C Chance fractures, as seen above, are a variant of the flexion-distraction injury of the spine. These fractures typically occur in the thoracolumbar junction, which spans from T11-L2. Flexion-distraction injuries result from sudden deceleration and most commonly occur in restrained passengers of motor vehicle collisions and people who have fallen from a height. These injuries are most commonly seen in people who wear only lap belts that are improperly positioned above the pelvic bones. This is especially common in pregnant or obese patients. A seat belt sign may be seen on physical exam. Radiographic findings in these injuries include posterior vertebral wall fracture, increased height of the posterior vertebra, and fanning of the spinous processes. The Chance fracture also involves anterior vertebral compression and significant distraction of the middle and posterior ligaments. Sagittal reconstruction is often necessary for proper diagnosis. Chance fractures are commonly associated with intra-abdominal injuries and a high index of suspicion should be maintained for bowel perforation or solid organ damage in patients with Chance fractures.

A five-year-old boy is brought to the emergency room for altered mental status. The family had a party at their house the night before. In the morning, they found their son on the floor surrounded by empty cans of beer. He appears sleepy, and on the way to the hospital, he vomited twice. On examination, the boy is sedated with sluggish pupils and flushed skin. Which of the following abnormalities would you expect with the boy's toxic ingestion? A. Abnormal head CT B. Hyperkalemia C. Hypoglycemia D. Metabolic alkalosis

C Ethanol acts as a CNS sedative in a dose-dependent manner in overdose. Ethanol intoxication commonly manifests as altered behavior, lethargy, coma, ataxia, slurred speech, hypothermia, bradycardia, hypotension, and respiratory depression. Rapid blood glucose measurements should be performed in all patients with altered mental status after ethanol ingestion. Decreased blood glucose below 40 mg/dL is well described in children who have ingested ethanol. This ethanol-induced hypoglycemia results from exhausted glycogen reserves.

A ten-year-old boy collapses on the football field and is quickly evaluated by the sports medicine doctor. He had been practicing on the field for approximately two hours, without any rest. His temperature is 105°F and his skin is sweaty. On testing his mental status, he can say his name and age but does not know where he is. Which of the following is the best initial treatment for this boy? A. Cool the body with fans B. Offer oral rehydration solution C. Provide cold water to drink D. Whole body cold-water immersion

C Heat stroke is a severe illness with mortality rates of up to 50%. Rectal temperature is usually > 104°F, and patients will have profuse sweating. In contrast, "classic" heat stroke is seen in elderly patients and is usually a slower onset, with the physical exam notable for dry, hot skin. Treatment of children with heat stroke consists of immediate whole body cooling, usually performed by cold water immersion. IV fluids should also be initiated as soon as possible, at a rate of 800 ml/m2 in the first hour.

A 17-year-old man presents after being thrown a far distance off of a horse. Which of the following is consistent with an anterior cord syndrome? A. Isolated motor function loss B. Loss of all motor and sensory function C. Loss of pain, temperature, and motor function D. Upper greater than lower motor weakness

C In order to fully understand the different syndromes of injuries to the spinal cord, it is imperative to understand the location of the tracts of the cord. The posterior columns carry tracts responsible for ipsilateral position and vibratory sensation. The lateral spinothalamic tract carries fibers for contralateral pain and temperature sensation. The lateral corticospinal tract is responsible for ipsilateral motor function. Syndromes may be incomplete depending on how much of the cord is affected by the injury. In the anterior spinal cord syndrome, just the posterior columns are preserved and so patients lose all pain and temperature sensation as well as motor function. In trauma, typically hyperflexion of the cervical spine causes the injury to the spinal cord.

A 45-year-old man presents to the emergency room after tripping over a curb. He is unable to put any weight on his right foot. On physical exam, there is bruising over the medial plantar surface and tenderness over the tarsometatarsal joint. Radiographs reveal an avulsion fracture of the second metatarsal and widening of the space between the medial cuneiform and base of the second metatarsal. Which of the following is the most appropriate treatment? A. Midfoot arthrodesis B. Non-weight bearing cast immobilization for 8 weeks C. Open reduction and internal fixation D. Walking boot for 4 weeks

C Open reduction and internal fixation is indicated for Lisfranc injuries with any evidence of instability or bony fracture. A Lisfranc injury is characterized by a disruption the tarsometatarsal joints, which connect the forefoot to the midfoot The injury usually results from excessive indirect rotational forces and axial loading through a hyper-plantar flexed foot. Common causes of Lisfranc injuries include motor vehicle accidents, falls, or sports. Patients usually present with severe foot pain and an inability to bear weight. Physical exam may reveal midfoot bruising of the plantar surface, generalized swelling, and tenderness of the tarsometatarsal joint. Radiographic findings may include disruption of second metatarsal, avulsion fragments, or malalignment of the fourth metatarsal and the cuboid bone. Operative management is indicated in patients with any evidence of instability or fracture. Posttraumatic arthritis is the most common complication of Lisfranc injuries.

A 42-year-old woman presents with pain in her elbow after she tripped over a curb and landed on her outstretched arm. Radiographs of the elbow show an anterior and posterior fat pad, but no obvious fracture or dislocation. What is the most likely diagnosis? A. Humeral shaft fracture B. Posterior elbow dislocation C. Radial head fracture D. Supracondylar fracture

C Radial head fractures are often radiographically occult and abnormalities within the soft tissues of the elbow may be the only clue to a fracture. On a normal lateral elbow radiograph, a very small strip of lucency is seen anteriorly, known as the anterior fat pad. If there is increased swelling in the joint from a fracture, the anterior fat pad becomes more prominent and balloons out, and has been dubbed the "sail sign." Additionally, the presence of a posterior fat pad is also indicative of a fracture. The posterior fat pad is normally not visible, so if a posterior fat pad is seen on radiographs, it denotes increased swelling in the joint and an underlying fracture. This patient's radiograph shows an anterior and posterior fat pad. In adults, this implies an underlying radial head fracture, whereas in children, a supracondylar fracture is more common.

A 7-year-old boy presents to the emergency department with an ankle injury. He fell while playing on equipment at a nearby playground. There is pain, swelling, and ecchymosis over the medial malleolus. An ankle X-ray is obtained and shows a fracture along the growth plate and into the epiphysis of the tibia. Which of the following is the most likely diagnosis? A. Greenstick fracture B. Salter-Harris type II fracture C. Salter-Harris type III fracture D. Torus fracture

C Salter-Harris type III fractures are intra-articular injuries that involve the physis and the epiphysis. These are often unstable fractures and are managed based on size and degree of displacement. Consultation with an orthopedic surgeon is recommended.

A 14-year-old girl presents to the ED with wrist pain one day after falling onto an outstretched hand while playing soccer. She has normal sensation and movement and a normal radial pulse. Her exam is unremarkable with the exception of tenderness at the anatomical snuffbox. X-rays of her wrist and forearm are normal. Which of the following is the next best step in management? A. No immobilization B. Sugar-tong splint C. Thumb spica splint D. Ulnar gutter splint

C Scaphoid fractures are relatively uncommon in children but are at risk of nonunion. A fracture through the proximal or waist (central ⅓) of the bone can decrease blood supply further, especially if the artery is disrupted. This causes poor healing conditions which can lead to nonunion or osteonecrosis. Patients with a scaphoid fracture may only have pain at the anatomical snuffbox after a fall onto an outstretched hand. Current recommendations are to place such patients in a thumb spica splint and refer to outpatient orthopedics to determine the need for further immobilization and repeat X-rays in two weeks.

A 3-year-old boy is eating with his brother in the other room when his mother hears coughing and choking. His brother reports that he had just eaten a handful of peanuts before the symptoms began. In the emergency department, the child has moderate respiratory distress with a respiratory rate of 30 breaths per minute and a saturation of 93% on room air. He is placed on oxygen by facemask with improvement in saturations to 96%. Faint expiratory wheezes are noted over the left lobe. The remainder of the examination is unremarkable. A chest radiograph is normal. Which of the following is indicated? A. Administration of IM epinephrine B. Administration of nebulized albuterol C. Emergency bronchoscopy D. Endotracheal intubation

C The onset of acute respiratory distress following consumption of peanuts should prompt consideration of both foreign body aspiration and anaphylaxis. This child's focal wheezing, located over the left lobe, make foreign body aspiration most likely If foreign body aspiration is suspected based on history and physical examination, emergent bronchoscopy should be performed. In fact, delayed bronchoscopy has been shown to increase morbidity and mortality in children with foreign body aspiration.

An 86-year-old woman trips over the curb while walking out to her mailbox and injures her shoulder. Radiographs reveal a minimally displaced proximal humerus fracture. She is neurovascularly intact. Which of the following is the most appropriate management? A. Open reduction and internal fixation B. Procedural sedation with closed fracture reduction C. Sling immobilization and discharge home D. Total shoulder arthroplasty

C The patient has a minimally displaced proximal humerus fracture. Humerus fractures occur primarily in older adults, often occurring as a result of a fall onto an outstretched and abducted arm. In younger individuals, this mechanism is more likely to result in a shoulder dislocation. Older adults, whose bones may be weakened from osteoporosis, are more prone to fracture. A careful neurovascular evaluation is paramount to identify injuries to nearby structures such as the axillary nerve, brachial plexus, or axillary artery. Most proximal humerus fractures are minimally displaced, as the joint capsule, periosteum, and surrounding musculature hold the fracture segments together. Treatment of a minimally displaced proximal humerus fracture is immobilization in a sling or sling and swathe device and referral to a rehab program. The most common complication of proximal humerus fracture is adhesive capsulitis (frozen shoulder). Early range of motion exercises are prescribed to reduce this complication. A less common, but devastating complication is avascular necrosis of the humeral head

A 37-year-old man is brought into the emergency department after being stabbed in the flank during a bar fight. On examination, the patient has 2/5 strength and decreased vibration sense in his left lower extremity as well as decreased pinprick sensation in his right lower extremity. Which of the following is the most likely pattern of this patient's injury? A. The corticobulbar tract was transected on the left B. The corticospinal tract was transected on the right C. The dorsal column was transected on the right D. The spinothalamic tract was transected on the left

D Brown-Séquard syndrome is a hemicord syndrome which manifests as ipsilateral loss of motor function, vibration, and proprioception and contralateral loss of pain and temperature sensation. Brown-Séquard syndrome most commonly occurs due to penetrating trauma to the spine but can less commonly result from lateral cord compression due to spine fractures, hematomas, herniated discs, or tumors. Loss of motor function occurs due to transection or compression of the ipsilateral corticospinal tract, which carries upper motor neurons from the motor cortex of the brain. The same is true of the ipsilateral dorsal column, which carries sensory neurons for proprioception and vibration to the sensory cortex. In contrast, the spinothalamic tract, which carries pain and temperature sensation, travels two levels along the spinal tract before decussating (crossing over), resulting in loss of pain and temperature sensation contralateral to the lesion. Thus, in Brown-Séquard syndrome, the spinothalamic tract is always damaged contralateral to the side of pain and temperature loss, in this case, on the left.

Which of the following distinguishes traumatic injuries of the thoracic spine from injuries to the remainder of the spinal column? A. The thoracic spine requires less force to injure than the cervical spine B. Thoracic spine injuries are less likely to be associated with complete cord injuries than are injuries at the thoracolumbar junction C. Thoracic spine injuries are more common due to relative mobility of thoracic vertebrae D. Thoracic spine injuries are more likely to be associated with cord injuries

D Due to its rigidity, the thoracic spine is less commonly injured than other spinal segment and requires a more severe traumatic force to cause injury. As such, thoracic spine injuries are commonly associated with intrathoracic injuries due to the severity of the traumatic force required to injure the thoracic vertebrae. Furthermore, the spinal canal in the thoracic spine is more narrow than in the cervical and lumbar spine, increasing the rate of spinal cord injury in trauma of the thoracic spine. Spinal cord injuries associated with thoracic spine injuries are more likely to be complete cord lesions than spinal cord injuries associated with cervical, lumbar, or transitional zone trauma.

A 42-year-old man presents via emergency medical services after an injury that occurred while he was working. There was an explosion at the chemical plant where he was employed. An initial survey of the patient shows deep-partial thickness burns of his neck and face along with burns of varying degrees on his torso and hands. There is soot in his nose and mouth. Which of the following is the most appropriate next step in managing this patient? A. Administer intravenous analgesics B. Administer tetanus prophylaxis C. Dress the exposed wounds D. Prepare for emergent endotracheal intubation

D Emergent intubation should be performed if there is any evidence of airway compromise including swelling or burns of the neck, burns inside the mouth, wheezing, facial burns, carbonaceous sputum, or soot inside the nose or mouth. Emergency management of the patient should include respiratory and circulatory status evaluation. The secondary examination should include the eyes for corneal burns, as well as estimating and recording the size and depth of all burns

Which of the following history or physical exam findings is most consistent with toxic acetaminophen ingestion? A. Anorexia and myalgia B. Jaundice with pruritus C. Nausea, vomiting, diarrhea D. RUQ abdominal tenderness

D Right upper quadrant abdominal pain and tenderness are clinical signs of hepatotoxicity and are typically seen two to three days after ingestion of a toxic dose of acetaminophen. This is classified as stage II of toxicity. During stage II, the symptoms seen in stage one (mild nausea, anorexia, and vomiting) typically resolve. Stage III occurs by days three to four and is characterized by fulminant hepatic failure. A toxic exposure in adults is > 200 mg/kg as a single ingestion or over a 24-hour period. It is also considered a toxic dose with > 150 mg/k per 24-hour period for at least two consecutive days. Treatment is guided by the Rumack-Matthew nomogram. Acetylcysteine therapy should be administered if there is a risk of liver damage as indicated by the nomogram.

Which of the following findings on electrocardiogram are indicative of left main coronary artery occlusion? A. Biphasic T waves in leads V2-3 B. Coved ST segment elevation > 2 mm followed by a negative T wave in leads V1-3 C. Horizontal ST depression with tall, broad R waves and upright T waves in leads V1-3 D. ST elevation in aVR > V1 with horizontal ST depression in I, II and V4-6

D ST segment elevation in lead aVR greater than 1 mm or greater than the elevation seen in the ST segment of V1 should prompt concern for occlusion of the left main coronary artery. The finding of ST elevation in aVR that > than that seen in V1 can distinguish occlusion of the left main coronary artery from the left anterior descending artery. It was also found that the extent of ST segment elevation in aVR correlated with increased mortality. Other ECG findings consistent with left main occlusion include horizontal ST depression in leads I, II, and V4-6.

A two-year-old girl is brought to your clinic by her father because of abdominal pain. This is accompanied by decreased energy, vomiting, and constipation. CBC with peripheral smear shows microcytic anemia with basophilic stippling. Which of the following is the most likely diagnosis? A. Acute lymphocytic leukemia B. Folate deficiency C. Iron deficiency anemia D. Lead poisoning

D Since lead blocks iron from being incorporated into heme, lead poisoning can look like iron deficiency in which there is microcytic anemia. To differentiate this from iron deficiency, look for basophilic stippling of RBCs accompanied by GI and CNS symptoms. Lead lines are found on imaging of long bones. Succimer is the treatment "it SUCCS to eat LEAD"

A 2-year-old unvaccinated boy is rushed to the emergency department with concerns for respiratory distress. His mother reports that he awoke in his usual state of health and was playing alone in the playroom when mom heard him have a coughing fit. Since that time, he has been choking and coughing, has had inspiratory stridor, and developed significant increased work of breathing. What is the most likely etiology of his stridor? A. Acute asthma exacerbation B. Croup secondary to parainfluenza virus C. Epiglottitis secondary to H. influenzae D. Foreign body aspiration

D The child's sudden onset of respiratory distress in an unobserved setting is suggestive of a foreign body aspiration. The child's inspiratory stridor is indicative of an upper airway obstruction, and he most likely has a laryngotracheal foreign body aspiration. Aspiration into the bronchi, and especially the right mainstem bronchus, is significantly more common than laryngotracheal aspiration Children with laryngotracheal foreign body aspiration require immediate medical attention for airway stabilization and removal of the foreign body. Notably, if a child is able to cough, the airway obstruction is partial. If the diagnosis is suspected, it should be further evaluated by bronchoscopy.

A 65-year-old man is brought in by EMS after collapsing with chest pain while he was working in his garden. The monitor shows ventricular fibrillation and CPR is in progress. Before he arrived in the emergency department, several shocks were administered as well as two doses of IV epinephrine. The most appropriate next step is administration of which of the following medications? A. Amiodarone B. Dopamie C. Magnesium sulfate D. Vasopressin

A Amiodarone is given as a 300 mg bolus for shock-refractory ventricular fibrillation (VF). This drug prolongs action potentials by inactivating sodium channels. It is used in a wide variety of dysrhythmias, including shock-refractory ventricular fibrillation and pulseless ventricular tachycardia (VT).

A 55-year-old woman presents to the Emergency Department with a rash on her left arm. She was stung by a wasp while attempting to destroy a nest in her garage. On examination, she has diffuse urticaria and biphasic wheezes. She says this happened to her when she was a child. She begins to vomit while you are examining her. Which of the following is the most likely diagnosis? A. Anaphylaxis B. Hymenoptera sensitization C. Systemic mastocytosis D. Type II hypersensitivity reaction

A Anaphylaxis is a life-threatening type I mast cell-mediated hypersensitivity reaction and is the likely diagnosis when any one of the following criteria is met: (1) hypotension after exposure to an allergen, (2) onset of illness involving the skin or mucosal surfaces with accompanying respiratory compromise or hypotension, or (3) two of the following after exposure to a suspected allergen: skin or mucosal tissue involvement, hypotension, respiratory compromise or gastrointestinal symptoms. Food is the most common trigger among children, and insect stings and medications are the most common causes among adults and the elderly. Approach to any patient with anaphylaxis begins with assessment of airway, breathing and circulation. If anaphylaxis is suspected based on the above criteria, intramuscular (IM) epinephrine 0.3 to 0.5 mg of 1:1,000 solution should be given (0.01 mg/kg 1:1,000 for children). The dose may be repeated every five to fifteen minutes depending on how the patient responds

A 22-year-old woman presents to the emergency department after developing a widespread rash following a bee sting. The patient reports she has been stung once previously but never had a reaction. She denies difficulty breathing but states she feels somewhat light-headed. She is otherwise healthy, and has no significant past medical history. Vital signs are T 37, BP 85/60, HR 100, RR 18, oxygen saturation is 98%. A diffuse urticarial rash is present on the patient's extremities. Which of the following is the next best step in management? A. IM epinephrine B. Nebulized albuterol C. Observation D. Oral diphenhydramine

A Anaphylaxis is characterized by upper airway obstruction, rash, bronchospasm, and hypotension or cardiovascular collapse. Although she does not yet have trouble breathing, epinephrine is indicated. Patients typically present with a combination of hives, facial edema, pruritus, respiratory difficulty, and hypotension in the setting of an inciting factor such as bee sting, peanuts, shellfish and other foods. Anaphylaxis generally does not occur during the patient's first exposure to the allergen, instead presenting following the subsequent exposures. Intramuscular epinephrine and the close monitoring of vital signs are the foundation of anaphylaxis treatment. Patients with a history of reactive airway disease may benefit from albuterol nebulizers as a supplement. Intramuscular epinephrine should be administered every 5-15 minutes until the symptoms resolve.

Which of the following describes a patient with Brown-Sequard syndrome? A. Ipsilateral loss of motor strength, vibratory sensation, and proprioception with contralateral loss of pain and temperature sensation below the level of injury B. Ipsilateral loss of pain and temperature and contralateral loss of motor strength, vibratory sensation, and proprioception C. Pain, loss of temperature below level of injury, and complete loss of motor function but retains proprioception and the ability to sense vibration and deep pressure D. Preservation of motor function with loss of proprioception and vibration below the level of injury

A Brown-Séquard syndrome results from hemitransection of the spinal cord with unilateral damage to the corticospinal and spinothalamic tracts. This injury is usually the result of penetrating injuries or a lateral mass fracture of the cervical spine. It is also caused by spinal cord tumors, infections, and ischemia. It is rarely seen in its pure form, typically occurring with incomplete involvement of related tracts. Prognosis is excellent, with most patients recovering.

A 27-year-old man who is tall and thin presents to the emergency room with moderate right-sided chest pain and dyspnea. He says it started quickly while he was watching television 30 minutes ago. He is tachypneic and tachycardic, however his heart rate and blood pressure are stable at this point. Lung exam reveals decreased breath sounds at his right lung field. Which of the following other physical exam findings would be expected in this patient? A. Decreased right-sided tactile fremitus B. Left-sided hyperresonance C. Mediastinal shift to the right side D. Tracheal shift to the left side

A Decreased tactile fremitus over the affected lung field is an expected finding in this patient who has signs and symptoms of a right-sided spontaneous pneumothorax. A pneumothorax is accumulation of air in the pleural space, that may be primary (occurring in the absence of underlying lung disease) or secondary to an existing pulmonary disorder. Chest pain and dyspnea are usually present, though degree depends on the extent of the pneumothorax. Most patients will note that symptoms began at rest. Treatment depends on the extent of pneumothorax. A small pneumothorax, affecting less than 20% of a hemithorax, can be observed. Simple aspiration drainage of pleural air with a small-bore catheter may be needed in larger pneumothoraces.

You are called to the emergency department to see a five-year-old boy for ingestion. He was playing in the garage when his mother found him with an opened bottle of antifreeze. The liquid was all over his mouth and clothes. He had two episodes of vomiting and fell asleep on the way to the hospital. On physical examination, you note tachycardia. Which of the following laboratory abnormalities would you expect in this type of ingestion? A. Calcium oxalate crystals in urine B. Decreased lactate levels C. Hypercalcemia D. Non-anion gap metabolic acidosis

A Ethylene glycol is commonly found in antifreeze. Early symptoms begin with nausea, vomiting, CNS depression. Late manifestations include anion gap metabolic acidosis, hypocalcemia, and kidney failure (secondary to deposition of calcium oxalate crystals in the renal tubules) Calcium oxalate crystals can be seen on urine microscopy. The evaluation of patients should include electrolytes (including calcium), acid-base status, kidney function, and ECG. Antidote is fomepizole

A three-year-old boy is brought to the emergency department due to acetaminophen ingestion. About four hours prior, he was found by his mother with an open bottle of acetaminophen and several tablets scattered on the floor. The mother was not sure how many tablets were missing. The boy had one episode of vomiting at home. He is asymptomatic upon arrival at the emergency room. On examination, the boy is active with normal vital signs and physical examination. Which of the following is the most appropriate next step in management? A. Get acetaminophen level 4 hours after ingestion B. Obtain transaminases, synthetic and renal function C. Perform immediate gastric lavage D. Treat with syrup of ipecac urgently

A If a toxic ingestion is suspected, a serum acetaminophen level should be calculated four hours after the reported time of ingestion. For patients who present to medical care more than four hours after ingestion, a stat acetaminophen level should be obtained. Acetaminophen levels obtained fewer than four hours after ingestion are difficult to interpret and cannot be used to estimate the potential for toxicity. The serum acetaminophen level is then plotted on the Rumack-Matthew nomogram and any level that is in the possible or probable hepatotoxicity range should then be treated with N-acetylcysteine.

A 35-year-old man presents with headache, nausea, and lightheadedness. The headache started one day after a flight from Boston to a ski resort in Colorado. He describes the headache as bifrontal and throbbing. The patient has normal vital signs and his neurologic exam is normal. The patient's presentation is consistent with which of the following disorders? A. Acute mountain sickness B. High-altitude cerebral edema C. Migraine headache D. Subarachnoid hemorrhage

A In order to diagnose AMS, the patient must have a recent gain in altitude which occurred at least several hours ago, a headache, and one of the following additional symptoms: gastrointestinal upset, generalized weakness, fatigue, dizziness, lightheadedness, or insomnia. The headache is generally bitemporal and throbbing. The cornerstone of management of AMS is to halt ascent until symptoms improve. Headaches can be treated with acetaminophen or ibuprofen. Supplemental oxygen may also reduce symptoms. Acetazolamide can be used to stimulate breathing and can be helpful for insomnia. If symptoms do not improve or worsen with conservative management, the patient should descend to lower altitudes.

Which of the following is the most appropriate first step in caring for a patient who presents with an ear laceration? A. Checking the patient for signs of altered consciousness and basilar skull fracture B. Irrigation of the wound with normal saline C. Local infiltration of lidocaine with epi D. Local infiltration of lidocaine without epinephrine

A Most ear lacerations are the result of blunt head trauma. Thus, it is imperative to rule out traumatic brain injury before addressing the wound. The exam should include looking for signs of altered consciousness or mental status, abnormal breathing pattern, and signs of basilar skull fracture. The signs of basilar skull fracture include: clear discharge from the nose or ears, hemotympanum, periorbital ecchymosis (raccoon eyes), and retro-auricular bruising (Battle's sign.) Impaired function of cranial nerves VI, VII, and VIII is also concerning for a basilar skull fracture, so in-depth assessment of extraocular movements, facial movement and symmetry, and hearing and balance should be performed.

A five-year-old girl is brought by her father to the clinic because of a cat bite. Yesterday, she was playing with a neighbor's cat that suddenly bit the girl's left hand. Her wound was immediately cleaned. The following day, the father noted increased swelling and redness of the girl's left hand. On physical examination, she has normal vital signs, and on the left hand are two puncture wounds with a surrounding 1 cm diameter of erythema and swelling. Which of the following is the best treatment for a suspected Pasteurella sp. soft tissue infection? A. Amoxicillin-clavulanate B. Clindamycin C. Erythromycin D. Vancomycin

A Most patients develop symptoms within 24 hours of the initial injury, and as early as three hours after a cat bite. Pain and swelling are prominent. Purulent drainage is noted in about 40 pecent of patients, lymphangitis in about 20 percent, and regional adenopathy in 10 percent. Cellulitis often occurs within 24 to 48 hours. Necrotizing fasciitis may occur. Pasteurella sp., including P. multocida, are usually susceptible to a number of antibiotics, including amoxicillin-clavulanate, piperacillin-tazobactam, doxycycline, fluoroquinolones, advanced cephalosporins, and carbapenems.

A 47-year-old man presents as a trauma activation after a head-on motor vehicle crash at 20 mph. He was a restrained driver and the airbags did deploy. There were no drugs or alcohol involved. He is uncertain if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously fractured femur. On primary survey, his airway is protected, he is breathing easily, is normotensive and has a GCS score of 15. Vital signs are within normal limits. Secondary survey is notable for a mildly tender right trapezius muscle, and an ecchymotic and deformed left femur with normal distal neurovascular function. The presence of which historical or physical finding necessitates cervical spinal imaging per NEXUS?' A. Distracting injury B. Mechanism of injury C. Paraspinal tenderness D. Possible loss of consciousness

A The (National Emergency X-Radiography Utilization Study) NEXUS is one of the best known clinical decision rules for clinical cervical spinal clearance. If all five of the criteria are satisfied, the NEXUS rules indicate that the patient can be clinically cleared of a cervical spinal injury. Presence of a single criterion necessitates imaging. A femur fracture is a distracting injury, thereby necessitating cervical imaging. CT imaging of the cervical spine is the initial test of choice to rule out a fracture.

A 26-year-old man presents to the emergency department after being the restrained driver in a motor vehicle collision. He is alert and interactive and complains of moderate abdominal pain. His vital signs are T 37.3°C, HR 99, BP 125/84, RR 19. His physical examination is significant for anterior abdominal wall bruising and mild diffuse tenderness to palpation of the abdomen. A bedside ultrasound assessment reveals the anechoic fluid around the spleen and kidney. Which of the following is the most appropriate next step in the management of this patient? A. CT imaging of the abdomen and pelvis B. Diagnostic peritoneal lavage C. Laparotomy D. Serial abdominal examinations for the next 48 hours

A The most commonly damaged intra-abdominal structures in blunt abdominal trauma are the liver and the spleen. Abdominal pain, distention, and abdominal wall bruising should raise suspicion for intra-abdominal injury. The focused assessment with sonography in trauma (FAST) is one of the primary diagnostic modalities for diagnosing serious intra-abdominal injury. It includes sonographic examination for free fluid in the pericardium, the hepatorenal and splenorenal recess, and the paracolic gutters and can be extended to include an examination of the thorax. Stable patients with a positive FAST should undergo a computed tomographic (CT) scan of the abdomen to reveal the source of the fluid.

A two-year-old boy was brought to the emergency department because of vomiting. About 30 minutes prior, he was found by his parents with an open bottle containing ferrous fumarate tablets. The mother estimates about five tablets are missing, and each tablet contains 65 mg of elemental iron. The boy had three episodes of non-bloody vomiting. The physical examination is essentially normal except for tachycardia. Which of the following is the next best step? A. Get serum iron levels 4 hours after ingestion B. Give activated charcoal immediately C. Obtain urinalysis D. Perform gastric lavage

A The patient has symptoms and a history compatible with iron toxicity. The severity of an exposure is related to the amount of elemental iron ingested. Ferrous sulfate contains 20 percent elemental iron, ferrous gluconate has 12 percent, and ferrous fumarate contains 33 percent. Iron is directly corrosive to the GI mucosa, which can lead to hematemesis, melena, ulceration, infarction, and potential perforation. Serum iron concentrations of < 500 µg/dL four to eight hours after ingestion suggest a low risk of significant toxicity, whereas concentrations of > 500 µg/dL indicate significant toxicity.

A 36-year-old man presents after being bitten by "something". He felt a pinprick sensation on his forearm while cleaning out his garage followed by worsening pain over the next sixty minutes that spread to involve his entire arm. Shortly after, he began having severe cramping of his chest and abdomen. What was he likely bitten by? A. Black window spider B. Brown recluse psinder C. Hornet D. Ixodes tick

A The venom is highly potent and results in release of acetylcholine resulting in neuromuscular symptoms and norepinephrine resulting in cardiovascular symptoms. Patients will typically recall a pinprick sensation at the site of the bite followed by mild erythema and swelling. Within minutes to an hour, the pain increases and spreads to the entire body. Severe cramping pain occurs in the chest, abdomen, and back and can mimic an acute abdomen. Systemic symptoms include nausea, vomiting, headache, and dizziness. Hypertension and tachycardia are common

A 19-year-old man presents to the ED with facial and mouth pain after being assaulted with a club. On physical exam, you note significant swelling over the left inferior and lateral face and misalignment of the inferior premolars. Which of the following is the most likely location of this mandibular injury? A. Body B. Coronoid process C. Ramus D. Symphysis

A This patient has signs and symptoms consistent with a mandibular fracture. The mandible is the second most commonly fractured facial bone behind the nasal bone. The most likely fracture location is the body of the mandible, which is more likely to show signs of obvious tooth misalignment on exam. Other signs and symptoms of a mandibular fracture include trismus, malocclusion of the bite, intraoral lacerations, and missing teeth. The tongue blade test is a way of detecting even subtle mandibular fractures. Plain mandibular X-rays and panoramic radiographs are screening tests for mandibular fractures; however, CT of the facial bones is the gold diagnostic standard. Management is variable depending upon location and whether the fracture is open or closed. Open fractures require IV antibiotics, such as penicillin or clindamycin, and hospital admission. Closed fractures may be discharged with dental follow-up. The patient should be given adequate oral analgesics and instructed to observe a soft diet and chew on the non-fractured side. Many fractures will require open reduction and internal fixation, but do not require admission initially if not open fractures.

A 34-year-old man presents to the ED with vomiting after exposure to pesticides while working as a farmer. Which of the following would you expect to find on physical exam? A. Bronchorrhea B. Dry mucous membranes C. Mydriasis D. Tachycardia

A This patient is exhibiting signs and symptoms consistent with cholinergic toxicity secondary to organophosphate poisoning. SLUDGE mnemonic: Salivation, Lacrimation, Urination, Diarrhea, GI cramps, and Emesis. Patients will also demonstrate diaphoresis, pupillary miosis, severe bronchorrhea, bradycardia, muscular fasciculations, paralysis, agitation, seizures, or even coma Atropine is a competitive inhibitor of acetylcholine at muscarinic receptors. The goal of treatment with atropine is to titrate to the drying of bronchial secretions. Pralidoxime (2-PAM) is the definitive antidote to organophosphate poisoning. Pralidoxime is only effective if given early as the organophosphate-acetylcholinesterase complex matures quickly resulting in the inability of 2-PAM to cause regeneration of the enzyme.

A 35-year-old man presents to the Emergency Department four hours after being bitten on his left hand by a spider while cleaning out his shed. He currently complains of whole arm pain as well as headache, severe back spasms, and abdominal pain. What is the treatment of choice to control his symptoms? A. IV calcium gluconate B. IV diazepam C. IV ketorolac D. IV normal saline

B Black widow bites occur most often between April and October and usually occur on the hands and forearms. Envenomation of a neurotoxic venom occurs when bitten. The neurotoxin causes receptor stimulation, pore formation, and release of neurotransmitters; predominantly acetylcholine and norepinephrine A target lesion with a blanched center and surrounding erythema may develop at the site of the bite and frequently localized diaphoresis near the site of where envenomation occurs. The clinical syndrome with envenomation is referred to as latrodectism. Patients frequently complain of muscle cramps and spasms in large muscle groups including trunk, back, and abdomen, however, physical examination rarely reveals rigidity. Pain and muscle spasms can be effectively controlled with liberal doses of opioids and benzodiazepines. If pain lasts for several days, can use Latrodectus antivenin

An 18-year-old man presents after being stabbed in the back. His vital signs are stable and his FAST examination is negative. Physical examination demonstrates a stab wound to the lower back located just to the left of the midline. The patient is unable to move his left leg and reports that his right leg is numb. Which of the following describes his syndrome? A. Anterior cord syndrome B. Brown-Sequard syndrome C. Central cord syndrome D. Spinal shock

B Brown-Séquard syndrome is a hemisection of the spinal cord most commonly occurring after a penetrating injury. In this syndrome, patients have proprioception and vibratory sensory loss on the ipsilateral side of the injury as well as loss of motor function on the same side. The contralateral side loses pain and temperature sensation since these fibers cross the spinal cord at the level of their nerve roots

A 32-year-old man presents to the emergency department with complaints of a headache. It started gradually earlier today and is associated with nausea and dizziness. He has had similar headaches in the past, but this one is not improving with ibuprofen and acetaminophen. He states he had to turn the heat on the night prior because it was so cold. He feels like he is beginning to feel a little better after coming in. Vital signs are within normal limits. Which of the following diagnostic studies is most likely to confirm the diagnosis? A. Arterial blood gas B. Carboxyhemoglobin C. CT of brain D. Lumbar puncture

B Clinical manifestations of CO poisoning can range from minor symptoms such as headache, nausea, vomiting, dizziness, myalgias or confusion, to more severe symptoms such as altered mental status, seizures and cardiac arrest. Delayed neurologic sequelae is a known complication of CO poisoning that may include persistent neurologic deficits (e.g., focal deficits, seizures) or more psychiatric and cognitive effects (e.g., apathy, memory deficits). A carboxyhemoglobin measurement of greater than or equal to 15% is considered diagnostic of CO poisoning. COHb can be reversed in four to five hours on room air, 60-85 minutes on supplemental 100% oxygen or 20-30 minutes on hyperbaric oxygen therapy.

A 19-year-old man presents to the emergency department after a motor vehicle collision. He is unconscious with a unilaterally dilated pupil. What is the most appropriate initial intervention? A. Determine GCS score B. Endotracheal intubation C. Immediate transfer to the ICU D. Insert two large bore IV lines

B Endotracheal intubation should be the initial clinical intervention when a patient presents unconscious with a suspected head injury in order to secure the airway. The primary survey consists of rapid assessment of the airway, breathing, and circulation, and then continues with assessing a patient's disability using screening tools such as the Glasgow Coma Scale followed by fully exposing the patient in order to perform a thorough inspection of the body. Once the primary survey is completed and life-threatening injuries are stabilized, the clinician can move onto the secondary survey which is a rapid identification and assessment of injuries that have the potential to become unstable. For instance, controlling bleeding or evaluating pelvic instability. When a patient initially presents to the emergency department, assessing the airway is the most important intervention and therefore endotracheal intubation should be the primary clinical intervention in an unconscious patient

A 34-year-old woman presents with elbow pain and diminished arm movement following a fall on her outstretched hand. Initial history and physical exam are notable for pain, swelling, and tenderness over the lateral elbow, and inability to fully extend the elbow. Which of the following is indicative of a radial head fracture? A. Displacement of the radiocapitellar line B. Posterior fat pad sign C. Pronator sign D. Wrist drop

B Patients with radial head fractures typically present with localized swelling, tenderness, and decreased motion of the elbow following a fall on an outstretched hand. Presence of an elbow joint effusion, as indicated by elevation of the anterior or posterior fat pads or both, points to an occult intra-articular fracture. The posterior fat pad is not seen on a normal lateral X-ray of the elbow and thus is a more reliable indicator of joint effusion. The anterior fat pad can be visible as a thin translucent line on a normal elbow radiograph, but may bulge away from the joint in the setting of an effusion creating the anterior 'sail sign'. Treatment of a nondisplaced radial head fracture includes a sling and outpatient orthopedic follow up.

A 35-year-old woman with a prior history of suicidal ideations is brought to the Emergency Department approximately 10 hours after ingesting an unknown quantity of acetaminophen and ibuprofen. She is complaining of nausea and abdominal pain. Her blood pressure is 150/80 mm Hg, heart rate is 90, respiratory rate is 18, and temperature is 36.8C. Physical examination reveals diffuse abdominal pain. What is the most appropriate next step in management? A. Administer glutathione B. Administer N-acetylcysteine C. Arrange for hemodialysis D. Determine acetaminophen level

B Risk of severe hepatotoxicity increases if the patient is not treated with N-acetylcysteine (NAC) within the first 8 hours after ingestion. If the patient presents after 8 hours from the time of the ingestion, a loading dose of NAC at the initial dose of 140 mg/kg should be administered without delay. Acetaminophen level as well as transaminases must be determined, but therapy should not be delayed while awaiting the results of the laboratory studies.

Which of the following is a feature of a subdural hematoma? A. Hematoma formation will not cross cranial suture lines B. It is often associated with concurrent brain injury and parenchymal damage C. It most commonly results from an arterial bleed D. Risk for this injury decreases with age

B Subdural hematomas are caused by tearing of bridging dural veins due to sudden acceleration-deceleration RF = Extensive atrophy of the brain (elderly and alcoholics), age < 2 years, low cerebrospinal fluid volume, prior head trauma, and anticoagulation subdural bleeds readily cross cranial suture lines, Radiographic findings include a crescent-shaped lesion that crosses suture lines on noncontrast CT

A 5-year-old boy is brought to the emergency department after being found unresponsive at home. He was found lying on the floor in his mother's room with prescription medications scattered all over. His mother called 911, and he was immediately rushed to the hospital by ambulance. On examination, the boy is sedated with a respiratory rate of 15/minute, blood pressure of 70/50 mm Hg, pulse oximetry of 92% on room air, pupils 1-2 mm and reactive to light, and 1+ reflexes on all extremities. Blood sugar is 200 mg/dL. An ECG reveals QTc interval prolongation, followed by polymorphic ventricular tachycardia with a rate of 190 bpm and QRS complexes twisting around the isoelectric line. Which of the following is the most likely medication ingested? A. Clonidine B. Methadone C. Propranolol D. Salicylate

B The boy has signs and symptoms consistent with opioid ingestion. Methadone ingestion can manifest with the classic opioid toxidrome of respiratory depression, sedation, and miosis. Signs of more severe toxicity can include hyporeflexia, hypotension, bradycardia, and hypothermia. Methadone is particularly associated with a prolonged QTc interval and risk of torsades de pointes Patients with significant respiratory or CNS depression should be treated with naloxone, get serial EKGs to look for prolonged QTc If a patient does develop a prolonged QTc, management includes close cardiac monitoring, repletion of electrolytes, and having magnesium readily available should the patient develop torsades de pointes.

A 42-year-old man with a history of hypertension presents to the emergency department by ambulance after his wife called 911 out of concern for a possible overdose. The patient is confused and unable to answer questions upon arrival. His blood pressure is 80/50 mm Hg, heart rate is 45 beats/minute, and respiratory rate is 12 breaths/minute. Electrocardiogram findings include a prolonged PR interval. His glucose is 60 mg/dL. Which of the following is the most likely explanation? A. Acetaminophen overdose B. Beta-blocker overdose C. Calcium-channel blocker overdose D. Opioid overdose

B The most commonly seen clinical manifestations of beta-blocker overdose include hypotension and bradycardia. Patients may also present with hypoglycemia, hyperkalemia, arrhythmias, and seizure activity. ECG can show prolonged PR or QRS intervals. Initial treatment is with boluses of isotonic intravenous fluids and atropine. Patients determined to have severe poisoning should be treated with intravenous glucagon, high-dose insulin (with glucose), calcium salts, and lipid emulsion therapy.

A 17-year-old baseball player presents to the emergency department complaining of sudden left shoulder pain. The patient states he heard his shoulder "pop" and felt pain as he was extending his arm back to throw a fastball. On examination, the patient is holding his left shoulder in abduction and external rotation with loss of the deltoid contour. There is limited and painful range of motion. Which of the following is the most likely diagnosis? A. Acromioclavicular joint injury B. Anterior glenohumeral dislocation of left shoulder C. Midshaft fracture of the left humerus D. Posterior glenohumeral dislocation of the left shoulder

B The patient suffered an anterior glenohumeral dislocation of his left shoulder. The shoulder joint is often injured during a fall on an outstretched arm, engaging in sports activities, a direct blow to the joint, or grand mal seizures. Patients often report hearing or feeling a pop during the incident and present with significant pain, limited range of motion, swelling, or deformity. Anterior shoulder dislocations are the most common type; however, they can occur posteriorly and inferiorly. Anterior dislocations result from a force applied to the shoulder while the arm is abducted and externally rotated such as while throwing a ball. On examination, the arm is held in abduction and external rotation (down adjacent to the body) with a loss of the deltoid contour when compared to the other shoulder, and the humeral head can often be palpated anteriorly beneath the clavicle. The patient will have very limited range of motion and be unable to touch the opposite shoulder. Complications of shoulder dislocations include fractures (e.g. Hill-Sachs lesion), soft tissue injury (e.g. Bankart lesion), nerve injury (e.g. axillary nerve), or vascular injury (e.g. axillary artery).

Which of the following laboratory findings suggests ethylene glycol ingestion? A. Anion gap 16 and pH 7.32 associated with vision changes B. Lactate 0.9 mmol/L, pH 7.12, and creatinine 2.5 mg/dL C. Osmol gap 20, anion gap 8, and ketonemia D. pH 7.10, lactic acid 5.5 mmol/L, and anion gap 21

B The toxic alcohols include ethanol, ethylene glycol, methanol, and isopropanol. Markers of intoxication with ethylene glycol include high anion gap metabolic acidosis with an absence of significant lactate or ketone concentrations, and calcium oxalate formation leading to acute renal failure. Therefore, lactate 0.9 mmol/L, pH 7.12, and creatinine 2.5 mg/dL would be characteristic of ethylene glycol poisoning Sodium bicarbonate may be used for urine alkalinization to improve acidemia. Ethanol or fomepizole may be utilized for acute management in conjunction with a nephrology consultation. Hemodialysis is indicated for ethylene glycol levels > 50 mg/dL. Adjunctive therapy includes thiamine and pyridoxine every four to six hours.

A 19-year-old farmer presents to the ED with vomiting, diarrhea, diaphoresis, wheezing, and excessive tearing. Vital signs are BP 150/100 mm Hg, HR 36 beats per minute, RR 28 breaths per minute, and T 98.6°F. Which of the following is the most appropriate initial step in management? A. Atropine B. Decontamination C. Endotracheal intubation D. High-dose insulin

B This patient is exhibiting signs and symptoms consistent with cholinergic toxicity secondary to organophosphate poisoning. Management of organophosphate poisoning should begin with decontamination. There are two keys to definitive treatment in patients with organophosphate poisoning. The first is to temporize the life-threatening signs and symptoms of cholinergic toxicity. Atropine is a competitive inhibitor of acetylcholine at muscarinic receptors. The goal of treatment with atropine is to titrate to the drying of bronchial secretions. Pralidoxime (2-PAM) is the definitive antidote to organophosphate poisoning. SLUDGE mnemonic: Salivation, Lacrimation, Urination, Diarrhea, GI cramps and Emesis. Patients will also demonstrate diaphoresis, pupillary miosis, bradycardia, muscular fasciculations, paralysis, agitation, seizures, or even coma.

A 21-year-old woman presents to the emergency department after an intentional ingestion. On physical examination, she is lethargic, flushed, hot to the touch, and her pupils are dilated. Vital signs include BP 130/90 mm Hg, HR 130 beats/minute, and RR 22 breaths/minute. After several minutes, she has a generalized tonic clonic seizure. What is the mechanism by which this class of medications causes cardiac toxicity? A. AV nodal blockade B. Fast inward sodium channel blockade C. Inhibition of the sodium-potassium-ATPase pump D. Rapid outward potassium channel blockade

B This patient is exhibiting signs and symptoms of a tricyclic antidepressant (TCA) overdose. TCAs act by fast inward sodium channel blockade, causing QRS complex widening (> 100 ms) on ECG. TCAs also have anticholinergic effects, which lead to a presentation of pupillary dilation, dry, hot, flushed skin, tachycardia, decreased or absent bowel sounds, and urinary retention, as well as rapid deterioration of mental status and seizures Another hallmark finding of TCA toxicity on ECG is a dominant terminal R wave in lead aVR. Management of TCA toxicity includes administration of sodium bicarbonate to combat the sodium channel blockade if there is widening of the QRS complex on ECG or telemetry.

A 17-year-old high school football player is seen in your clinic with neck pain after practice. He reports the pain started after he tackled a teammate and was associated with tingling in both arms. What is next best step in management? A. Analgesia and observation B. Cervical spine immobilization C. Neurosurgical referral D. X-ray of cervical spine

B This patient is reporting neck pain and neurological symptoms after football practice, which is concerning for a cervical spinal cord injury. Initially, the patient's spine should be immobilized while simultaneously assessing the airway, breathing, and circulation (ABCs). The most common mechanism of injury in adolescents is via axial loading, which can cause a cervical fracture of C1 (Jefferson fracture). This is most likely to occur in football, when a player runs headfirst into another player, and diving, when a diver's head hits the bottom of the pool.

A 22-year-old woman presents to the emergency department after spilling hot tea on her left forearm. She is complaining of pain and redness in the area. Physical exam shows a red, painful, and tender area without blister formation. What is the most likely diagnosis? A. Deep partial-thickness burn B. Full-thickness burn C. Superficial burn D. Superficial partial-thickness burn

C A superficial burn (also known as first degree burn) is characterized by erythema, pain, and tenderness without blister formation. The area typically looks similar to a sunburn. Treatment for this degree of burn is symptomatic (NSAIDs, topical analgesics) Second degree burns are better characterized as superficial or deep partial-thickness burns. In superficial partial-thickness burns, the superficial dermis is also injured. There is blistering of the skin and pain with palpation. These burns usually heal within 14 to 21 days and there may or may not be scarring. Deep partial-thickness burns extend into the reticular layer of the dermis. There will be damage to the sweat and sebaceous glands. The skin will demonstrate blistering and the exposed dermis will be pale in color Full-thickness burns (also known as third degree burns), destroy all epidermal and dermal structures. These are typically painless

A 58-year-old woman with a history of previous cerebrovascular accident presents to the emergency department by ambulance due to concern for possible overdose. According to her husband, at home she was vomiting and complaining of nausea and ringing in her ears. The patient is confused and unable to answer questions upon arrival. Her blood pressure is 90/57 mm Hg, heart rate is 112 beats/minute, respiratory rate is 28 breaths/minute, and temperature is 103.1°F. Which of the following interventions should be avoided if possible? A. Administration of IV fluids B. Arterial blood gas analysis C. Endotracheal intubation D. Hemodialysis

C Aspirin is used as an analgesic and is a widely prescribed antiplatelet agent for patients with cerebrovascular and cardiovascular disease. Aspirin is converted to salicylic acid in the body and peak levels in overdose are often delayed for up to six hours or later. Symptoms of aspirin overdose include nausea, vomiting, diarrhea, vertigo, and tinnitus. Vital sign abnormalities include tachypnea, tachycardia, and elevated temperature. Initial management includes rapid stabilization of the patient's airway, breathing and circulation, and gastrointestinal decontamination with charcoal. Providers need to be aware that airway management can worsen the condition of patients with aspirin overdose. The brief moment of apnea that occurs in preparation for intubation can cause acute and significant worsening of the patient's respiratory alkalosis.

A patient presents with symptomatic bradycardia following an overdose of metoprolol. After securing the airway, the most appropriate next step is administration of which of the following? A. Adenosine B. Amiodarone C. Atropine D. Glucagon

C Atropine is used to treat symptomatic bradycardia. Metoprolol is a beta-adrenergic antagonist. Patients with overdoses of beta-blockers usually become symptomatic within two to six hours after ingestion. Bradycardia and hypotension are the most common effects. Treat hypotension with IV boluses of isotonic fluid and hypoglycemia with boluses of 50 percent dextrose in water. IV glucagon, vasopressors, and calcium salts can be used depending upon the severity of the overdose. Glucagon is considered to be antidote for beta blocker overdose

You evaluate a 10-year-old girl in the ED because of headache. She has been complaining of headache, nausea, and dizziness. She was seen in clinic yesterday and was diagnosed with a viral illness. Her symptoms got worse, and she seems confused. The girl denies rhinorrhea, fever, loss of consciousness, trauma, or burns. Her mother and older brother also complain of headache. You obtain labs that show an elevated carboxyhemoglobin level. Which of the following is the most appropriate therapy? A. Amyl nitrite B. Methylene blue C. Oxygen D. Supportive care

C Carbon monoxide (CO) is the most common gas involved in pediatric exposures. Early symptoms are nonspecific, including headache, malaise, nausea, and vomiting. At higher exposure levels, patients can develop mental status changes, confusion, ataxia, syncope, tachycardia, and tachypnea. On exam, patients may have cherry-red skin. Evaluation should include a carboxyhemoglobin level in all symptomatic patients, arterial blood gas and creatine kinase in severely poisoned patients, and an ECG in any patient with cardiac symptoms. Treatment requires the administration of 100 percent oxygen to enhance elimination of CO. Severely poisoned patients might benefit from hyperbaric oxygen.

A 3-year-old boy is brought to the emergency department by his father because of possible poisoning. He was found in the garage with furniture polish on his cheeks, mouth, and clothes. The father saw him coughing but denies choking or vomiting. On examination, the boy is active with normal vital signs. Which of the following is the next best step? A. Consult pulmonology B. Give activated charcoal C. Obtain chest x-ray D. Perform gastric lavage

C Hydrocarbon toxicity can result from ingestion of furniture polish. A transient and mild CNS depression is commonly noted after hydrocarbon ingestion or inhalation. Aspiration is characterized by coughing, which usually is the first clinical finding. It is important to obtain a chest radiograph. Standard mechanical ventilation, high-frequency ventilation, and ECMO have all been used to manage the respiratory failure and ARDS associated with severe hydrocarbon-induced pneumonitis.

Which of the following is the immediate first step in the treatment of chemical injuries to the eye? A. Application of topical antibiotics to prevent infection B. Complete ocular examination, including dilated fundoscopic examination C. Manual removal of particulate material followed immediately by irrigation with saline until the pH is 7.0 D. Topical steroids and artificial tears

C Immediate irrigation with normal saline is the initial step even before complete exam when a patient presents with a chemical eye injury. A lid speculum should be placed and topical anesthesia applied. Irrigation may be administered by a handheld bottle or through IV tubing with an irrigation lens. The pH should be checked with a pH strip and irrigation discontinued when the pH reaches 7.0. Any particulate matter should be removed prior to irrigation if it is a reactive substance such as ammonium hydroxide crystals since fluid may dissolve these causing more injury. The upper lid should be everted to check for any particulate matter.

A 72-year-old man presents to the emergency department with chest pain. During triage, he collapses and nursing staff cannot feel his pulse. The patient is taken to a treatment room where cardiopulmonary resuscitation is initiated and ventricular fibrillation is noted on EKG. What is the next best step? A. Administration of amiodarone B. Cardioversion C. Defibrillation D. Two minutes of chest compressions

C In a sudden episode of cardiac death, the initial rhythm is most likely ventricular fibrillation, or ventricular tachycardia that degenerates into ventricular fibrillation. In a witnessed cardiac arrest, if the initial rhythm is amenable to defibrillation, a shock should be administered as soon as possible.

A 30-year-old man presents to the emergency department after being involved in a head-on motor vehicle crash. He is complaining of severe pain in his right hip. On exam, his right leg appears to be shortened and is held slightly flexed, internally rotated, and adducted. Range of motion is severely limited due to pain. An anterior-posterior plain radiograph is negative for fractures, but the right femoral head appears smaller than the uninjured side. Which of the following is the most likely diagnosis? A. Anterior hip dislocation B. Avascular necrosis of the femoral head C. Posterior hip dislocation D. Slipped capital femoral epiphysis

C Posterior hip dislocations are most commonly associated with high-energy trauma such as motor vehicle collisions, falls from significant height, and high impact sports. Artificial hips can dislocate with less force. Posterior hip dislocations account for 90% of all hip dislocations. Patients typically present with severe pain, an inability to bear weight, and deformity. Range of motion will be severely limited. A detailed neurovascular exam should be conducted to rule out sciatic nerve injury. In posterior dislocations, the affected leg tends to be held in slight flexion, adduction, and internal rotation. Plain radiographs are first-line imaging for diagnosing hip dislocations and associated fractures. A posteriorly dislocated femoral head will appear smaller than the contralateral side on anteroposterior film. After ruling out life-threatening injuries, the hip should be reduced within six hours.

A 43-year old woman presents to the Emergency Department after being bitten on the lip by her dog. The laceration is approximately four centimeters long and approximate 1.5 cm deep, extending vertically from the lower vermilion border to the inner oral mucosa. After thorough irrigation and debridement, what is best method for wound closure? A. Delayed primary closure B. Primary closure with skin adhesive glue C. Primary closure with sutures D. Secondary closure

C Primary closure can be performed on the scalp, face, torso, and extremities other than the hands and feet. Primary closure can be accomplished through several different methods, including absorbable and non-absorbable sutures, skin adhesive glues, staples, and surgical tapes. Suturing allows for the most meticulous closure, which is required when managing wounds to the face Puncture wounds, wounds to the hands and feet, and wounds in high-risk patients should receive prophylactic antibiotics with amoxicillin/clavulanate. In penicillin allergic patients, clindamycin plus trimethoprim-sulfamethoxazole can be used. Delayed primary closure should be considered for contaminated or gaping wounds. Skin adhesive glue is most useful for wounds that have sharp, clean edges and are in clean, nonmobile areas, such as the forehead. Animal bites to the hands and feet should be allowed to heal by secondary closure or intention

A 2-year-old girl with mild intermittent asthma is playing in the other room when her father hears acute onset of choking and coughing. The episode continues for five minutes, and he brings her to the Emergency Center. On exam she is awake and alert but coughing intermittently. Her respiratory rate is 25 breaths/minute with a saturation of 94% on room air. She has mild intercostal retractions, and wheezing is present over the left lateral and posterior lung fields. Chest radiographs reveal hyperinflation of the left lobe. Which of the following is indicated? A. Albuterol with ipratropium B. Ampicillin C. Bronchoscopy D. Intramuscular dexamethasone

C The child's clinical presentation is concerning for a bronchial foreign body aspiration. The classic triad of foreign body aspiration includes sudden onset of coughing, wheezing, and decreased air entry, although these symptoms are not universally present. The right mainstem bronchus is the most common location of foreign body aspiration. It is most common during the third year of life. Partial obstruction of the lower airway may manifest as wheezing. On chest radiography, hyperinflation may be noted distal to the obstruction, as the object may cause partial obstruction and air trapping. Thus, if a foreign body is not visualized by radiography but is suspected based on history and examination, the patient should undergo further evaluation with bronchoscopy. Multiple studies have shown that delaying bronchoscopy may increase both morbidity and mortality.

A five-year-old girl is rushed to the ED because of possible ingestion. She was unattended for a few minutes and later found playing with her grandmother's bag. The grandmother's bag contains over-the-counter medications and herbal products. The girl complained to her grandmother that her ears were buzzing. Upon arrival at the ED, the girl had one episode of vomiting. Her examination was normal except for diaphoretic skin. Which of the following is the medication that most likely caused her symptoms? A. Acetaminophen B. Chlorpheniramine C. Ibuprofen D. Oil of wintergreen

D The girl manifests signs and symptoms of salicylism. Oil of wintergreen contains 5 g of salicylate in one teaspoon and ingestion of very small volumes of this product has the potential to cause severe toxicity. Early signs of acute salicylism include nausea, vomiting, diaphoresis, and tinnitus. Moderate salicylate toxicity can manifest as tachypnea, tachycardia, and altered mental status. Signs of severe salicylate toxicity include hyperthermia, coma, and seizures. initial treatment should include gastric decontamination with activated charcoal.

A 3-year-old girl was brought by her parents to the ED because of a possible ingestion. The girl was caught with an open bottle of amitriptyline although the mother is not sure how many tablets were missing. The girl did not experience any mental status changes, vomiting, abdominal pain, or fever. She arrived at the ED within 60 minutes of her possible ingestion. On examination, she is alert, active, with tachycardia, dry mucous membranes, and pupils 5-6 mm. Which of the following is the antidote for this type of ingestion? A. Flumazenil B. N-acetylcysteine C. Naloxone D. Sodium bicarbonate

D The girl possibly took amitriptyline, which is a tricyclic antidepressant (TCA). Cardiovascular and CNS symptoms dominate the clinical presentation of TCA toxicity. Patients often develop features of the anticholinergic toxidrome such as delirium, mydriasis, dry mucous membranes, tachycardia, hyperthermia, mild hypertension, urinary retention, and slow GI motility. CNS toxicity can include lethargy, coma, myoclonic jerks, and seizures Initial management should be directed to supporting vital functions. ECG should be obtained as soon as possible and followed serially to monitor for progression of toxicity. Sodium bicarbonate is the antidote

A 1-year-old boy presents unconscious to the emergency department with multisystem trauma after he was a passenger in a motor vehicle accident. He is placed in a cervical collar. Which of the following, can definitively clear the cervical spine? A. C-spine CT scan B. C-spine MRI C. C-spine radiograph D. Clinical clearance

B A cervical spine MRI scan is the definitive way to diagnose and clear a cervical spine injury on patients of all ages. This diagnostic study allows for clear visualization of the ligaments, intervertebral disc spaces, spinal cord, and bones. If a patient is young, unconscious, or unable to communicate, it is difficult to clinically clear the cervical spine. Obtaining a cervical spine X-ray should be the initial course of action to determine whether or not there is movement between the bones A CT scan of the cervical spine would be the next ideal imaging technique, but this is best to further investigate the bones and not the ligaments or spinal cord.A 42-year-old woman presents to the emergency department after a suicide attempt. The patient was depressed two days ago and took an entire bottle of acetaminophen. She initially felt slightly nauseous and generally unwell but was otherwise asymptomatic. A family member convinced her to come to the emergency department for further evaluation.

A 45-year-old chemist presents to the emergency department after accidentally spilling elemental sodium on his left hand and forearm 30 minutes prior to arrival. What is the most appropriate next step? A. Application of topical calcium gluconate B. Copious irrigation with water C. Cover the affected area with mineral oil D. Intravenous fluid resuscitation

C The first step in managing elemental metal burns is to covering the affected area in mineral oil, sand, or foam from a Class D fire extinguisher. Chemicals that should not be immediately irrigated with water include dry lime, elemental metals (e.g. sodium, potassium, magnesium, and phosphorus), and phenols. Treatment for elemental metal burns involves removal of the substance and the affected area covered in mineral oil to prevent further exposure to air and moisture

A patient presents to the emergency department after a motor vehicle collision with a complaint of dyspnea and pleuritic chest pain. Physical examination reveals diminished breath sounds on the left and a chest X-ray demonstrates mediastinal shift to the right. Which of the following is the most appropriate first-line treatment for this condition? A. Observation B. Pleurodesis C. Thoracentesis D. Thoracostomy

D A thoracostomy is the most appropriate first-line treatment for a tension pneumothorax. A tension pneumothorax occurs when there is a progressive increase of air in the pleural space without a place for the air to be released. Patients present with diminished breath sounds and increased percussion over the affected area, pleuritic chest pain, hypotension, tachypnea, and tachycardia.

A 50-year-old woman presents to the emergency department after taking an overdose of propranolol. Which of the following describes the mechanism of action with this agent? A. Decreased membrane-stabilizing activity B. increased production of cyclic adenosine monophosphate C. Inhibition of alpha-receptors D. Inhibition of beta-receptors

D The most commonly seen clinical manifestations of beta-blocker overdose include hypotension and bradycardia.

A 15-year-old girl presents after a suicide attempt. She reports taking a bottle of over-the-counter pills about 12 hours ago but does not remember the name of the drug. Her symptoms include nausea, vomiting, and diaphoresis. Initial lab work reveals mildly elevated AST and ALT. What drug did she most likely ingest? A. Acetaminophen B. Diphenhydramine C. Ibuprofen D. Pseudoephedrine

A Acetaminophen overdose can lead to the production of the toxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI), which can cause cell necrosis when the antioxidant glutathione is depleted. he first 12-24 hrs can bring non-specific malaise, nausea, vomiting, and pallor. The next stage over the subsequent 12-24 hrs can include liver enlargement, elevated liver enzymes, and right upper quadrant abdominal pain. The third stage occurring 3-5 days after ingestion includes the return of nausea, vomiting, along with worsening liver enzymes and symptoms of liver failure (hypoglycemia, jaundice, encephalopathy, coagulopathy). The fourth stage is characterized by complete recovery or progression to liver failure. N-acetylcysteine works mainly by increasing available glutathione, which then detoxifies the NAPQI.

Which of the following is the treatment of choice in preventing acute mountain sickness? A. Acetazolamide B. Dexamethasone C. Ginkgo biloba D. Nifedipine

A Acute mountain sickness (AMS) is characterized by symptoms similar to those with a mild viral illness or "hangover" including headache, nausea, vomiting, fatigue, dizziness, and difficulty sleeping. Symptoms typically occur within hours of reaching a high altitude (generally > 8,000 feet) and peak in 24-48 hours. Slow ascent to allow time for acclimatization is the best method of prevention. When that is not possible or when there is a previous history of acute mountain sickness with ascent, use of acetazolamide (125-250 mg twice daily from one day prior to ascent and continuing for 48 hours after reaching altitude) has been shown to prevent the majority of symptoms.

A 7-year-old boy is involved in a rollover motor vehicle collision. He arrives intubated by the paramedic service. On exam, you note him to be flexing both upper extremities. Which of the following is an indicator of cerebral herniation? A. Bradycardia B. Hyperthermia C. Hypotension D. Tachypnea

A Cushing triad is usually a pre-terminal event seen in patients with increased intracranial pressure and cerebral herniation. It is associated with decreased level of alertness, hypertension, bradycardia, and irregular, decreased respirations.

A mother brings in her 8-year-old son in for evaluation after stepping on a nail with his bare right foot in their unfinished basement this morning.He was able to pull the nail out of his foot and the nail measured one inch. Examination of his foot reveals a nontender 2 mm puncture wound with no surrounding erythema. He completed his DTaP (Pediatric-Diphtheria-Tetanus-acellular Pertussis) vaccination series three years ago. What is the most appropriate next step? A. Administer tetanus immunoglobulin B. Clean the wound and discharge home C. Order a foot x-ray D. Prescribe antibiotics

B Antibiotics (D) are not indicated as there are no signs of infection at this time, but patients should be counseled on the signs and symptoms of infection including fever, swelling, warmth, drainage, increasing pain, and spreading erythema. A tetanus immunoglobulin (A) is administered in high risk wounds in non-immunized patients. An X-ray (C) is indicated if there is concern for retained foreign body or underlying fracture. This patient was able to pull out the nail and did not have tenderness on exam.

A 20-year-old man presents to an urgent care clinic complaining of right foot pain after landing wrong while playing basketball. On physical exam, he has maximal tenderness over the lateral foot. A radiograph is obtained and shows an avulsion fracture at base of 5th metatarsal. Which of the following is the most likely diagnosis? A. Bennett fracture B. Jones fracture C. Rolando fracture D. Smith fracture

B This man has a Jones fracture. A Jones fracture is a transverse fracture at the fifth metatarsal base, 1.5-3 cm distal to the proximal tuberosity. The most common mechanism of injury is significant adduction while the foot is plantar flexed. Initial treatment involves immobilization with a posterior splint, nonweightbearing status, and orthopedic referral in 3-5 days. Adjunctive therapies should include icing the area, elevation, and analgesics. Diaphyseal fractures often require surgical fixation. A Bennett fracture is a fracture of the first metacarpal base, which extends into the carpometacarpal joint. Rolando fracture is a comminuted version of a Bennett fracture. In Rolando fractures, the bony fragments often form a T or Y pattern at the metacarpal base. A Smith fracture is a fracture of the distal radius with palmar displacement of the radius fragment.

A 35-year old man presents to the emergency department with superficial facial lacerations and epistaxis. After treating the epistaxis, you examine the nasal mucosa. Which of the following is considered an emergency, requiring urgent treatment? A. A deviated septum B. Closed nasal fracture C. Septal hematoma D. Trauma to Kiesselbach plexus

C A septal hematoma is considered an emergency. The problem is that the perichondrium, which supplies nutrition to the septum, is no longer in contact with the septum because of the intervening hematoma. Thus, the septal cartilage can necrose leading to a perforated septum. Septal hematomas should be drained acutely and the nose packed to keep the perichondrium in contact with the septal cartilage.

A four-year-old girl is seen at the ED because of possible ingestion. She was unattended for several minutes when she went through her grandmother's bag containing bottles of bethanecol, clonidine, diphenhydramine, and fluoxetine. Upon arrival at the ED, her examination reveals temperature of 38°C, heart rate of 120, respiratory rate of 16, blood pressure 85/56, pupils 5 mm equal and reactive and dry skin. Which of the following is the most likely medication that caused the girl's findings? A. Bethanecol B. Clonidine C. Diphenhydramine D. Fluoxetine

C The girl has clinical findings of anticholinergic poisoning that consists of hyperthermia, tachycardia, mydriasis, and dry skin. Other symptoms include decreased bowel sounds, urinary retention, disorientation, bizarre behavior, paranoia, delirium, visual hallucinations, and, in severe cases, seizures. The classic description of anticholinergic intoxication is known as: "red as a beet," "dry as a bone," "hot as a hare," "blind as a bat," and "mad as a hatter".

Which of the following drugs can cause mydriasis in overdose? A Hydromorphone B. Lorazepam C. Meperidine D. Paraquat

C At therapeutic doses, meperidine causes miosis (pinpoint pupils). However, unlike most other opioids, meperidine can cause mydriasis (dilated pupils) in cases of toxicity. Increased muscle tone, twitching, and tremors may also be seen with meperidine overdose Meperidine is not routinely used for the management of acute pain in the emergency department. Meperidine can also potentially interact with monoamine oxidase inhibitors and cause serotonin syndrome.

A 13-year-old boy is brought to the urgent care clinic by his mother. He was struck in the eye with a baseball while playing with classmates during recess. He complains of blurred vision and excruciating eye pain. Examination of the eye reveals decreased visual acuity, miosis, photophobia, and grossly visible blood in the anterior chamber. Which of the following is the most likely diagnosis? A. Corneal abrasion B. Hyphema C. Retinal detachment D. Ruptured globe

B About 70% of traumatic hyphemas occur in children, with a peak incidence between 10 and 20 years of age. Following blunt eye injury, the bleeding usually stops quickly due to increased intraocular pressure, vessel spasm, and clot formation.

A 66-year-old man presents after a landscaping injury. He was pruning bushes with motorized shears when he slipped and cut his right thigh. He put a towel on the wound and was able to walk to the emergency department. He has no other injuries and his vital signs are within normal limits. He takes warfarin for atrial fibrillation. When you examine his wound, you note a seven-centimeter simple laceration with blood continuously oozing from the defect. Which of the following is the appropriate next step? A. Apply a tourniquet proximal to the wound B. Apply direct pressure to the wound C. Irrigate the wound D. Reverse his anticoagulation

B Arterial bleeding is under pressure and will spurt, while venous bleeding will generally be a continuous slow ooze. Direct pressure to the wound is an effective technique to gain early control of a bleeding injury. Pressure compresses the vasculature and gives time for a clot to form at the site of the injury. Applying a tourniquet proximal to the wound is appropriate when a patient is exsanguinating from an extremity wound. In this case, the patient has active slow bleeding and direct pressure is an appropriate, less aggressive first step in bleeding control.

A 16-year old boy presents with a superficial bite to his right arm. He states he was camping in the woods and a bat flew into his tent. Which of the following treatments should this patient receive? A. Human rabies immunoglobulin and 3 doses of inactivated rabies vaccine over 7 days B. Human rabies immunoglobulin and 4 doses of inactivated rabies vaccine over 14 days C. Human rabies immunoglobulin only D. Inactivated rabies vaccine onl

B The rabies virus enters the CNS and causes a wide range of symptoms from headaches, anorexia, hallucinations, agitation to seizures, and hydrophobia. The human rabies immunoglobulin is a one time dose where as the inactivated rabies vaccine is given 4 times over 14 days.

Which of the following is most likely to be associated with a bilateral interfacetal dislocation? A. Anterior cord syndrome B. Brown-Sequard syndrome C. Central cord syndrome D. Complete cord transection

D Bilateral facet dislocation is an unstable injury that occurs from forceful hyperflexion of the neck. It occurs when the articular masses of one vertebra dislocate anteriorly and superiorly from the articular surface of the vertebra below it causing anterior displacement of the spine. This is commonly associated with a complete spinal cord injury due to transection of the cord at the level of the injury. Diagnosis is made by radiographic evidence of displacement of the superior vertebral body anteriorly more than one half of its width

A 13-year-old boy is brought to the emergency room by his mother after a suicide attempt. She reports that he swallowed a bottle of pills but is unsure of what he ingested. His vital signs are BP 90/60, HR 135, RR 16, and T 100.3°F. On exam, the patient is somnolent, his pupils are dilated, mucous membranes are dry, and skin is warm and flushed. Which of the following substance did this patient most likely ingest? A. Amitryptyline B. Methylphenidate C. Oxycodone D. Sertraline

A Amitriptyline is a TCA and the most frequent cause of poisoning in this class of drugs. Overdose can lead to a variety of anti-cholinergic symptoms, including tachycardia, dry mouth, mydriasis, hyperreflexia, warm flushed dry skin, gastrointestinal complaints, urinary retention, and confusion or agitation Initial management may include gastric decontamination with activated charcoal but is otherwise supportive, depending on the presenting symptoms (intravenous fluids, cardiac agents, respiratory support).

A 64-year-old woman is brought to the emergency room by ambulance after being the restrained driver in a motor vehicle collision. She fell asleep at the wheel, crossed the highway median, and hit another car head-on at 60 miles per hour. There was a fatality in the other vehicle. On examination, the patient is alert and screaming in pain. Her exam is notable for absent shoulder shrug, 0/5 strength of the upper extremities and 5/5 strength of the lower extremities. Her X-ray reveals anterior displacement of the occiput relative to the atlas. Which of the following is the most likely diagnosis? A. Atlanto-axial dislocation B. Atlanto-occipital dislocation C. Translational fracture-dislocation D. Traumatic spondylolisthesis

B Atlanto-occipital dislocation, commonly referred to as internal decapitation, is a highly unstable and severe ligamentous injury at the craniocervical junction. It is often immediately fatal. The most common mechanism of injury is high-speed motor vehicle collision. The classic presentation is cruciate paralysis, with paralysis of the upper extremities and sparing of the lower extremities. However, atlanto-occipital dislocation can present with a wide spectrum of symptoms, ranging from isolated neck pain to lower cranial nerve deficits, unilateral or bilateral weakness, and quadriplegia. Management of atlanto-occipital dislocation in the field and the emergency department includes confirmation of a stable airway, hemodynamic stabilization, and application of rigid cervical collar. Definitive management is through halo placement.

When prescribing metronidazole which of the following should patients be specifically instructed to avoid? A. Dairy products B. Ethanol C. Excessive water intake D. Leafy green vegetables

B Metronidazole is used in the treatment of various parasitic and bacterial infections, but patients should be specifically instructed to avoid alcohol intake, as even a small amount of alcohol ingestion during metronidazole therapy may result in intense vomiting, also known as a disulfiram-like reaction