E2 ER

B. The presence of uterine cramping, vaginal bleeding, passage of tissue, and an open cervical os in a pregnant woman is consistent with an incomplete abortion. Uterine curettage would be the therapy.

33-year-old woman complains of vaginal bleeding and abdominal cramping. She passed some blood clots. Her last menstrual period was 6 weeks previously. On examination her cervical os is open to 1 cm. Her quantitative hCG level is 2000 mIU/mL. Which of the following is the most likely diagnosis? A. Ectopic pregnancy B. Incomplete abortion C. Completed abortion D. Incompetent cervix

D. In an adolescent who has significant menorrhagia requiring transfusion, the incidence of coagulopathy approaches 20% to 30%. Von Willebrand disease is the most common etiology, and will often respond to desmopressin (DDAVP). Coagulopathy should be ruled out prior to starting estrogen therapy, although sometimes this is impossible given laboratory constraints. IV progestin has no role in this condition. Endometrial ablation is appropriate for older women who have finished child bearing, and in whom the endometrium has been assessed for pathology. Endometrial ablation should not be performed on younger patients.

A 16-year-old adolescent girl is brought into the ED with complaints of significant vaginal bleeding with her menses. She bleeds 5 days each month with heavy flow, utilizing 25 to 30 pads. She is tired and gets dizzy during menses. On examination, her BP is 80/60 mm Hg and heart rate 120 beats per minute. Her external genitalia are normal; there are no lesions of the cervix or vagina. The uterus is normal sized and anteverted. There are no masses or tenderness. The pregnancy test is negative. Her hemoglobin level is 7 g/dL. The emergency physician orders a transfusion. Which of the following is the best next step? A. Screen for sexually transmitted infections. B. Begin intravenous progestin. C. Consult a gynecologist for endometrial ablation. D. Screen for coagulopathy.

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

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

B. This patient displays signs of impending airway obstruction. His worsening airway edema, despite appropriate medical therapy, dictates intubation before complete airway occlusion and a cricothyroidotomy is required. There is no wheezing to suggest bronchoconstriction that could be treated with a bronchodilator such as albuterol. Stridor is a worrisome sign of upper airway obstruction. Normal respiratory rate and oxygen saturation should not delay intubation as falling oxygen saturation is a late sign of respiratory failure. Cricothyroidotomy is only indicated after all other measures have failed.

A 20-year-old man presents to the emergency department after being stung by a bee. His skin is red and covered with welts. He has obvious swelling of his lips and tongue, but no wheezes. After treatment with appropriate medications, he complains of throat swelling and his voice is hoarse. He has stridorous inspirations but a normal respiratory rate and oxygen saturation. What is the most appropriate management of this patient airway? A. Continued observation as long as oxygen saturation remains normal B. Call anesthesia and prepare for RSI. C. Begin high-dose nebulized albuterol and continue to observe. D. Prepare for cricothyroidotomy.

C. Migraine headaches are described as unilateral and throbbing with nausea, photophobia, and phonophobia.

A 22-year-old woman complains of headache of 2 hours duration that is described as unilateral and throbbing with nausea, photophobia, and phonophobia. Which of the following is the most likely diagnosis? A. Cluster headache B. Brain tumor C. Migraine headache D. Tension-type headache

C. In general, any woman in the childbearing age group with abdominal pain or abnormal vaginal bleeding should have a pregnancy test. If pregnant, then ectopic pregnancy should be ruled out.

A 22-year-old woman complains of lower abdominal pain and vaginal spotting. Which of the following tests is the first priority? A. Pelvic ultrasound B. KUB (kidneys, ureters, bladder) radiograph C. hCG level D. Chlamydia antigen test of the cervix

C. Although cervical motional tenderness is not specific for acute salpingitis, and can be seen with other acute inflammatory conditions of the lower abdomen such as diverticulitis and appendicitis, it is a classic finding of pelvic inflammatory disease.

A 22-year-old woman is noted to have lower abdominal pain associated with some dysuria and abnormal menses. Her appetite has decreased recently. The pregnancy test is negative. Which of the following findings would most likely suggest pelvic inflammatory disease? A. Endometrial biopsy showing atypical cells B. Vaginal wet mount demonstrating clue cells C. Cervical motion tenderness on physical examination D. Pain on rectal examination

A. A large number of women who undergo methotrexate treatment of ectopic pregnancy will have some abdominal discomfort. As long as there are no signs of rupture such as hypotension, severe pain, or free fluid on ultrasound, expectant management may be practiced.

A 22-year-old woman underwent methotrexate treatment for an ectopic pregnancy 1 week ago and complains of lower abdominal cramping. She denies vaginal bleeding, dizziness, or vomiting. On examination, her blood pressure is 120/80 mm Hg and her heart rate is 80 beats per minute. The abdomen reveals mild tenderness. Which of the following is the best management? A. Observation B. Surgical management of the ectopic pregnancy C. Administration of folinic acid D. Transfusion of 2 units of red blood cells

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

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

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

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

C. This is a healthy individual with CAP who can be treated as an outpatient with an oral macrolide. She has no risk factors for drug-resistant Streptococcus pneumonia nor any indications for admission.

A 25-year-old woman with no past medical history presents with fever and productive cough. Her vital signs include temperature 38.8°C (101.9°F), heart rate 115 beats per minute, respirations 20 breaths per minute, blood pressure 115/89 mm Hg, and pulse oximetry 97% on room air. On examination, rhonchi are present in the right lung field. Chest x-ray shows a right middle lobe infiltrate. Which of the following should her treatment include? A. Admission for intravenous ceftriaxone and vancomycin B. Admission for intravenous ceftriaxone and azithromycin C. Outpatient treatment with oral azithromycin D. Outpatient treatment with oral amoxicillin

A. No imaging is necessary. If the patient has no risk factors in the history and physical examination for serious disease other than sciatica, treat conservatively and do not perform any diagnostic tests in the ED

A 27-year-old woman with a 1-week history of progressive pain radiating from the lumbar spine down the back of the leg presents to the ED. Her physical examination is normal except for complaints of back pain with movement. Which of the following is the most appropriate imaging test? A. No imaging is necessary; attempt conservative therapy. B. Obtain plain films of the lumbar spine. C. Perform MRI. D. Perform CT.

D. This patient likely has a completed abortion with the resolution of symptoms following passage of tissue and now with a small uterus and closed cervical os. Nevertheless, there is still a possibility of ectopic pregnancy and perhaps the "tissue" passed was only blood clot. The tissue should be sent for pathologic analysis. Also, a repeat hCG level should be performed to ensure that all tissue has passed. The hCG level should fall by about 50% in 48 hours if all tissue has passed. A plateau in the hCG level may indicate incomplete abortion or ectopic pregnancy. Dilation and curettage would generally be performed, and if chorionic villi found the diagnosis is miscarriage; absence of chorionic villi establishes the diagnosis of ectopic pregnancy which may be treated by surgery or methotrexate.

A 28-year-old woman complains of lower abdominal cramping pain for about 3 hours, and passed what was described as "liver-like" tissue, after which her pain resolved. In the ED, her blood pressure is 120/70 mm Hg and heart rate is 80 beats per minute. Her uterus is firm and the cervix is closed. The hCG level is 2000 mIU/mL. Transvaginal sonography reveals no intrauterine pregnancy. Which of the following is the next step? A. Laparoscopy B. Methotrexate therapy C. Progesterone level D. Repeat hCG level in 48 hours

C. Neuroimaging is indicated in this patient prior to lumbar puncture given his altered mental status. Given the high suspicion for bacterial meningitis, antibiotic administration should not be delayed for the head CT. It is expected that one would obtain blood cultures and administer dexamethasone prior to the antibiotics in this case.

A 30-year-old man presents with altered mental status, fever, and nuchal rigidity. You suspect bacterial meningitis. Which of the following is the appropriate order of your actions? A. Head CT, lumbar puncture, blood cultures, steroids, antibiotics B. Blood cultures, head CT, lumbar puncture, steroids, antibiotics C. Blood cultures, steroids, antibiotics, head CT, lumbar puncture D. Lumbar puncture, blood cultures, steroids, antibiotics, head CT E. Head CT, blood cultures, steroids, antibiotics, lumbar puncture

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

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

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

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

D. Imaging is the best way to assess for TOA. Tubo-ovarian abscess is often subtle in its presentation and may not be associated with fever or elevated WBC. Most TOAs can be treated medically with antibiotics rather than requiring surgical therapy.

A 32-year-old woman is noted to have a 2-day history of low-grade fever and lower abdominal tenderness. The examination reveals cervical motion tenderness and adnexal tenderness. Which of the following is best in assessing for possible tubo-ovarian abscess? A. Degree of temperature B. Elevation of leukocyte count C. Pelvic examination revealing adnexal mass D. Ultrasound of the pelvis E. Rebound tenderness of the abdominal examination

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

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

D. This patient is appropriate for oral combination contraceptive therapy. She does not have contraindications, does not seem to require sampling of the endometrium, and there does not seem to be a structural etiology for the bleeding. Intravenous estrogen is usually reserved for women with signifi cant active bleeding and requires hospitalization.

A 32-year-old woman is seen in the ED with heavy vaginal bleeding. She states that she has had irregular menses for 3 years, and at times has "baseball-sized clots" pass vaginally. On examination, her BP is 120/70 mm Hg and heart rate 90 beats per minute. Her uterus is 4-week size and without tenderness. There are no abnormalities on pelvic examination including speculum examination of the cervix and vagina. Approximately 30 cc of dark blood is noted in the vaginal vault and a moderate flow of blood from the cervix. Her hemoglobin level is 10 g/dL. Which of the following is the next appropriate step? A. Begin intravenous estrogen. B. Administer intramuscular progestin. C. Transfuse 2 units of packed erythrocytes. D. Begin oral contraceptives at 3 pills per day.

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

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

D. Xanthochromia in cerebrospinal fl uid is most concerning for subarachnoid hemorrhage. Because it results from hemoglobin metabolism, xanthochromia may take up to 12 hours to develop.

A 34-year-old woman is brought into the ED for "the worst headache of her life." She has some lethargy, photophobia, and nuchal rigidity. A lumbar puncture is performed after examining her eye grounds. Which of the following findings in cerebrospinal fluid is most concerning for subarachnoid hemorrhage? A. Red blood cells B. White blood cells C. Elevated opening pressure D. Xanthochromia

A. In vitro fertilization with embryo transfer produces a rate of coexisting intrauterine pregnancy and ectopic pregnancy of up to 3% (markedly higher than the spontaneous rate of 1:10,000). Thus, a woman who has undergone in vitro fertilization who presents with abdominal fluid and hypotension must be suspected as having an ectopic pregnancy, even when an intrauterine pregnancy has been visualized on sonography.

A 42-year-old woman complains of an acute onset of significant abdominal pain of 6 hours duration. She states that she underwent in vitro fertilization and is currently 8 weeks pregnant. Her blood pressure is 90/60 mm Hg and her heart rate is 110 beats per minute. Her quantitative hCG level is 22,800 mIU/mL. Transvaginal sonography reveals a singleton intrauterine gestation with cardiac activity, and a moderate amount of free fluid in the cul de sac. Which of the following is the most likely diagnosis? A. Heterotopic pregnancy B. Ruptured corpus luteum C. Cirrhosis with ascites D. Urinary tract infection

F. This patient is 42 years old with DUB and hence, an endometrial sampling should be performed. In general, the endometrium should be assessed for women above age 35 years before any hormonal therapy is initiated. The blood sugar does not need to be acutely lowered. Although the uterus is enlarged and irregular indicating possible uterine fi broids, an evaluation should be performed prior to hysterectomy such as pelvic ultrasound and endometrial sampling.

A 42-year-old woman is seen in the with profuse vaginal bleeding. She has a history of diabetes mellitus. On examination, her BP is 100/60 and heart rate 105 beats per minute. Her uterus is irregular and enlarged and nontender. There is active bleeding arising from the uterus. Her hemoglobin level is 9 g/dL, glucose level 140 mg/dL and her pregnancy test is negative. Which of the following is the best management of this patient? A. Begin IV estrogen therapy. B. Begin oral progestin therapy. C. Begin oral contraceptive therapy. D. Lower the blood sugar. E. Refer the patient for hysterectomy. F. Perform endometrial sampling.

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

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

B. The history of alcoholism, presence of periodontal disease, duration of illness, symptoms and signs, and radiographic findings suggest an anaerobic source. Clindamycin provides the appropriate antimicrobial coverage.

A 55-year-old man with a history of alcoholism complains of a month of subjective fevers, productive cough with greenish sputum tinged with blood. Examination reveals poor dentition with halitosis, coarse breath sounds, and clubbing of his fingers. On chest x-ray, there is a 2-cm cavitary lesion with an air-fluid level in the right lower lobe. Which of the following is the most appropriate treatment? A. Isolate the patient and initiate antituberculosis treatment. B. Start intravenous clindamycin. D. Schedule a bronchoscopy. E. Discharge with oral amoxicillin-clavulanate.

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

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

D. This patient is a candidate for inpatient treatment due to his comorbidities and abnormal vital signs. However, he does not appear to require ICU admission. Thus, ceftriaxone and azithromycin are the best options of those listed.

A 65-year-old smoker with past medical history of chronic obstructive pulmonary disease and diabetes presents with productive cough, chills, and pleuritic chest pain. His vital signs include temperature 38.9°C (102.1°F), heart rate 110 beats per minute, blood pressure 140/89 mm Hg, respiratory rate 24 breaths per minute, and pulse oximetry 92% on room air. On examination, he has a barrel chest with diffuse wheezes bilaterally. His chest x-ray reveals a left-lower-lobe infiltrate and pleural effusion. Which of the following is the best treatment? A. Outpatient treatment with azithromycin B. Outpatient treatment with levofloxacin C. Inpatient treatment with ceftriaxone, azithromycin, and vancomycin D. Inpatient treatment with ceftriaxone and azithromycin

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

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

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

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

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

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

C. Although these are all appropriate interventions, this patient has significant hypoxia and respiratory distress despite noninvasive supplemental oxygen administration. Thus intubation is required.

An 89-year-old was brought by ambulance from a nursing home for fever and cough. His vital signs include temperature 39.9°C (103.9°F), heart rate 120 beats per minute, blood pressure 89/69 mm Hg, respiratory rate 36 breaths per minute, and pulse oximetry 88% on a nonrebreather face mask. He is clammy and lethargic. He has coarse breath sounds bilaterally although decreased on the left. Which of the following is the most appropriate initial intervention? A. Administer intravenous antibiotics B. Draw blood cultures C. Intubation D. Obtain a chest x-ray

A. Although the triad in the question is considered classic, studies have found that it is only present in less than half of the cases. If headache is added to the other 3, then at least 2 of the 4 symptoms are present in approximately 95% of patients.

Approximately what percentage of patients with bacterial meningitis present with the classic triad of fever, neck stiffness, and altered mental status? A. <50% B. Between 51%-75% C. Between 76%-99% D. >99%

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

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

A. The first patient is most likely to have a potentially life-threatening condition (hypertensive crisis).

Several patients have been brought into the ED with a chief complaint of headache. Which of the following patients should be seen first (ie, which is most likely to have a potentially life-threatening condition)? A. A 52-year-old man with headache of 8-hour duration, and blood pressure of 210/120 mm Hg. B. A 32-year-old woman with severe throbbing headache involving the right side of her head. C. A 32-year-old woman who underwent an outpatient bilateral tubal ligation under spinal anesthesia and now complains of severe bilateral headache, especially with sitting up. D. A 35-year-old woman with severe headache and a diagnosis given to her of pseudotumor cerebri.

D. Watching the ETT pass through the vocal cords is the best way to assure proper placement. CXR has no role in differentiating between endotracheal and esophageal intubation. The other choices are helpful but not failsafe.

The best way to confirm endotracheal tube placement is A. Chest x-ray B. End tidal CO2 C. Breath sounds heard in both lung fields D. Watching the ETT pass through the vocal cords

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

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

D. All adults with suspected bacterial meningitis get a third-generation cephalosporin and most institutions advocate for vancomycin to cover drug-resistant Streptococcus pneumoniae. Ampicillin is added because this patient is older than the age of 50.

Which of the following are the appropriate empiric antibiotics to administer to a 65-year-old man with suspected bacterial meningitis? A. Vancomycin alone B. Vancomycin and ceftriaxone C. Vancomycin and ceftriaxone and amoxicillin D. Vancomycin and ceftriaxone and ampicillin

D. The L4-L5 interspace is the most commonly affected.

Which of the following describes the most common location of herniated disc of the lumbar spine region? A. L1-L2 B. L2-L3 C. L3-L4 D. L4-L5

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

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

B. Succinylcholine transiently increases serum potassium levels. It is presumptively contraindicated in renal failure patients who often have elevated potassium levels. Acute burns are not a contraindication. Beginning 2 to 3 days after a burn, acetylcholine receptor upregulation can lead to hyperkalemia. Neither coronary artery disease nor sepsis is a contraindication to the use of succinylcholine.

Which of the following is a contraindication to succinylcholine? A. Acute burns B. Acute renal failure C. History of coronary artery disease D. Sepsis

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

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

C. Urinary retention with overflow incontinence is the most sensitive finding for cauda equina syndrome (90%).

Which of the following is the most sensitive finding for cauda equina syndrome? A. Decreased anal sphincter tone B. Saddle anesthesia C. Urinary retention D. Weakness or numbness in the low extremities

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

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

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

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

C. The most common cause of airway obstruction is the tongue and/or soft tissues of the upper airway. No other adjuncts may be necessary for initial management except relieving the obstruction with airway repositioning. This should certainly be the first step, and there is no need to wait for the code cart before performing this maneuver. There is no indication for chest compressions in a patient with palpable pulses. The patient will require BVM ventilation after airway repositioning and placement of an oral airway. If the patient is easy to ventilate, reversible causes of respiratory depression, such as a narcotic overdose, should be investigated and may eliminate the need for RSI.

You are the first person on scene to a code blue in your hospital. You arrive to find an elderly woman who is unconscious, has a weak pulse and does not appear to be breathing. Your first steps are A. Wait for the code cart to arrive and then intubate the patient. B. Begin chest compressions and mouth-to-mouth resuscitation. C. Attempt to remove any foreign body from the mouth and reposition the airway with chin lift or jaw thrust. D. Begin bagging the patient immediately.