Emergency Medicine SHELF Questions and Answers Scored A

Emergency Medicine SHELF Questions and Answers Scored A Which headache meds should never be combined? - ANS- ergotamine and triptans should never be combined because they both have vasoconstrictive effects, which can lead to complications such as stroke or myocardial infarction. What is the first line med for migraine with auro + vomiting - ANS- first line abortive med for migraine with auro (esp repeated vomiting) - IV prochlorperazine What type of fractures are common low-impact injuries and which are high-impact in elderly? - femoral neck - femoral head - intertrochanteric fractures - ANS- Femoral neck fractures and intertrochanteric fractures are common injuries on a low-impact fall to the hip in the elderly. Intertrochanteric fractures typically result in bruising because the fracture site is extra-capsular Posterior hip dislocation and femoral head fractures commonly occur in high-impact falls (dashboard injuries) Define: rupture of small penetrating artery rupture of a saccular aneurysm - ANS- rupture of small penetrating artery = intracerebral hemorrhage rupture of a saccular aneurysm = berry aneurysm = subarachnoid hemorrhage What is the best diagnostic test for boorehave syndrome? - ANS- hemodynamically stable, contrast esophagography with gastrografin is the preferred confirmatory test. NOT hemodynamically stable, CT scan of the chest is the best test What tests do you order for a patient with concerns of a lower GI bleed? (hemodynamically stable vs unstable) - ANS- Hemodynamically stable - colonoscopy requires bowel prep and will be unreliable in an urgent situation Hemodynamically unstable - angiography because it can be done quickly without the need for bowel prep ( you could do a CT angiography first before proceeding with invasive catheter angiography) When should you be conscerned for bowel perf vs SBO? - ANS- This patient presents with diffuse abdominal pain, nausea, vomiting, high-pitched bowel sounds, and a distended and diffusely tender abdomen, all of which suggest bowel obstruction. If the patient develops guarding or rebound tenderness and bowel sounds are absent, be concerned for a perf What complication after cardiac catheterization can lead to livedo reticularis?- - ANS- cholesterol embolization is a potential complication that can lead to ischemia in many organs, often including the kidney How do nitrates work to reduce myocardial oxygen demand? - ANS- Nitrates, such as nitroglycerin, cause arterial and venous vasodilation by inducing smooth muscle relaxation. Anginal pain relief is mainly achieved by venous dilation (venous pooling), which leads to decreased end-diastolic pressure (i.e., decreased preload), reduced myocardial wall tension, and improved myocardial perfusion. The decreased preload results in reduced heart size and decreased myocardial oxygen demand. What is the management for patient with HELLP at 35 weeks pregnant - ANS- HELLP - Hemolysis, elevated liver enzymes, low platelets. If a patient is over 34 weeks pregnant, then immediate delivery Mag sulfate is indicated in all patients with HELLP for seizure prophylaxis What is the diagnostic test for central retinal vein occlusion? - ANS- Fluorescein angiography (FA) is indicated as a next step to confirm the diagnosis of central retinal vein occlusion (CRVO), evaluate the severity of CRVO, and decide whether laser photocoagulation should be performed. What is TB adrenalitis - - ANS- This is adrenal insufficiency caused by TB, which can occur in patietns in a coutnry with high burden of tb What type of ulcers are you concerned for in burn patients? - ANS- Curling ulcers are a subtype of stress gastritis seen in patients with extensive burns and occur due to hypovolemia and subsequent hypoperfusion of the stomach. The resultant ischemic tissue injury to the stomach epithelium results in an interruption in the normal mucosal barrier of the stomach, and ulcer formation What is the difference between superficial second degree burns, deep second degree burns, and third degree burns? - ANS- Superficial partial thickness burn (superficial second degree burn) is known for blanching and blistering and being extremely tender Deep partial thickness burn (deep second degree burn) is known for blistering as well but as less tender and do not blanch Third degree burns are painless with no blanching that appear black, gray or white and leathery How can you tell the difference between infective endocarditis and a perivalvular abscess? - ANS- Conduction abnormalities on ECG (e.g., AV block) occur when the abscess extends to cardiac conduction tissues, which signals that the disease is not just infective endocarditis but also a perivalvular abscess What are the causes of vasovagal syncope? - ANS- Causes can include pain, fear, the sight of blood, or emotional stress. Patients usually experience a presyncopal prodrome, as seen here. Patients with syncope may also experience myoclonic jerks that last for less than 15 seconds evidence of bronchial wall fibrosis (tram-track opacities) is code for which disease? - ANS- bronchiectasis What is your first thought if someone is intubated and then has assymetrical chest rise and decreased breath sounds on the left - ANS- Absent or decreased breath sounds on the left suggest inadvertent right mainstem bronchus intubation, which is more common than inadvertent left mainstem bronchus intubation because the right mainstem bronchus is more vertically oriented than the left mainstem bronchus at the bifurcation of the trachea. A CT scan of the head shows a hyperdense fluid collection in the right medial temporal lobal and uncal herniation of the hippocampa gyrus. Which cranial nerve is likely affected? - ANS- oculomotor - CNIII What is the first line treatment for symptomatic bradycardia? - ANS- Atropine is an anticholinergic agent that is used to increase heart rate. Intravenous atropine is the first-line treatment in patients who present with symptomatic bradycardia when there are no reversible causes that can be immediately identified How does pulmonary contusion appear on chest xray? - ANS- Pulmonary contusion shows up as patchy infiltrates on chest xray How does AS lead to increased myocardial oxygen demand? - ANS- In AS, blood flow from the left ventricle to the aorta is obstructed by the narrowed aortic valve opening (increased afterload), which, over time, results in left ventricular hypertrophy (LVH). LVH leads to increased left ventricular oxygen demand, resulting in myocardial ischemia (angina) during periods of strenuous exercise or stress. What is amebiasis? - ANS- This is caused by protozoan entamoeba histolytica. Patients present with liver abscesses and bloody diarrhea. It can take several weeks to years for extraintestinal amebiasis to manifest What is the test to diagnose intestinal malrotation in infants? - ANS- Intestinal malrotation often presents with acute bilious vomiting in a 3-4 week infant. On xray you will see no gas in the distal small intestine. You must order an upper GI contrast series to diagnose What is the pathophys for cholelithiasis? - ANS- This condition is caused by increased intraluminal gallbladder pressure as a result of gallbladder contraction against an occluded cystic duct, most commonly due to gallstones? What is the treatment for a jellyfish sting? - ANS- Applying topical vinegar for 30 seconds reduces venom discharge from the nematocysts of Australian and Indo-Pacific box jellyfish. Next, any remaining attached tentacles should be carefully pulled off the patient (use gloves if available). Although the rescuer may sustain a minor sting, the latter does not pose a risk to the rescuer; after the removal, the rescuer must rinse the hands with seawater. What are the ideal antibiotics for aspiration pneumonia? - ANS- Intravenous broad-spectrum antibiotics with anaerobic coverage (ampicillin-sulbactam or carbapenems) are the preferred empiric antimicrobial treatment for lung abscesses and also provide coverage against gram-positive cocci. How do you differentiate bacterial keratitis and HSV keratitis? - ANS- bacterial - unilateral progressive eye pain, eye redness, impaired vision, and excessive tearing. Together with a round corneal infiltrate and a hypopyon. Tx with topical floxacin hsv - bilateral eye redness and pain. slit lamp examination (e.g., dendritic or geographic corneal lesion and vesicles) . Treat with topical ganciclovir When deciding between intubation and non-invasive PPV, what is a reason to go straight to intubation? - ANS- A patient with AMS cannot protect their airway and therefore cannot be put on PPV due to risk of aspiration When should you be concerned for thermal inhalation injury? - ANS- - If burns involved more than 30-40% opf body - singed nasal hair and eyebrows *Patient is at risk of upper air way edema and will need intubation What is the first line therapy for a patient with hyperkalemia and ekg changes? - ANS- calcium gluconate is first line. Sodium bicarb and insulin are other ways to reduce potassium after calcium gluconate What is the treatment for suspected carbon monoxide poisoning? - ANS- Patients with suspected carbon monoxide poisoning are generally treated with 100% oxygen via a nonrebreather mask. However, hyperbaric oxygen therapy is indicated to accelerate the elimination of COHb if any of the following are present: COHb > 25% (or > 15% in a pregnant woman), neurological manifestations (e.g., confusion, loss of consciousness, seizures, focal neurological deficits), ECG changes or clinical features of acute myocardial ischemia (e.g., chest pain), and severe acidosis (pH < 7.1). List the diseases associated with the following? c-anca p-anca anti-smith anti-GBM ADAMTS-13 - ANS- c-anca- granulomatosis with polyangitis p-anca - microscopic polyangitis anti-smith - SLE anti-GBM - good pasture syndrome. characterized by hemoptysis (alveolar hemorrhage) and nephritic syndrome ADAMTS-13 - thrombotic thombocytopenic purpura (TTP) How do you differ lead poisoning from acute intermittent porphyria? - ANS- lead poisoning may present (after acute or chronic exposure) as abdominal pain, constipation, and confusion with peripheral neuropathy. However, the peripheral neuropathy primarily affects motor nerves and results in extensor weakness ("wrist/ankle drop"). Additionally, lead poisoning generally results in anemia (classically with basophilic stippling) and produces neuropsychiatric deficits in memory and concentration, rather than symptoms of psychosis such as hallucinations seen in AIP What is vasa previa and what is placenta previa - ANS- Both are types of antepartum bleeding that are painless. Placenta previa is when the placenta blocks the cervical os and vasa previa is when the umbilical cord blocks the cervical os. If the fetus is unstable, that gives indication it is the umbilical cord and vasa previa causing the problem What is the presentation of hypertensive encephalopathy and hypertensive retinopathy - ANS- In hypertensive encephalopathy, a patient would have a systolic >180 or diastolic >120 and confusion, nausea, vomiting In hypertensive retinopathy, a patient would have papilledema How should you increase oxygenation (PO2) for people with ARDS? - ANS- You can increase FiO2 Increasing the positive end-expiratory pressure (PEEP) will help distend the alveoli (thereby increasing alveolar ventilation as well as decreasing the work of breathing) and increase oxygen diffusion into the pulmonary capillaries. Patients with severe ARDS often require higher levels of PEEP to help recruit alveoli and improve gas exchange. Using lower tidal volumes (lung protective ventilation of ∼ 6 mL/kg) improves mortality risk in patients with ARDS, What is the first line treatment for those with sigmoid volvulus (not strangulated)? - ANS- After fluid and electrolyte resuscitation, endoscopic detorsion (via sigmoidoscopy) is the best initial treatment for patients with sigmoid volvulus and no signs of peritonitis (e.g., abdominal rigidity/rebound tenderness) How can you differentiate TRALI and TACO post blood transfusion? - ANS- *Both occur about 6 hours post infusion TACO (transfusion associated circulatory overload) - is volume overload 2/2 to transfusion of blood products. Sys include elevated JVP, crackles, etc. TRALI (transfusion related acute lung injury) - Similar to TACO, patients would also present with acute dyspnea and diffuse bilateral opacities on chest x-ray. What differentiates TRALI is the presentation of hypotension and fever What should you do if you have a traumatic loss of a permanent tooth? (tooth is still in hand) - ANS- Avulsion of a permanent tooth is a dental emergency. The tooth should be manually replanted in the socket as soon as possible by the patient or someone else. This helps maintain viability of certain cells. If you need to store the tooth, place it in cold milk or the patients saliva What is the presentation of a thoracic aortic rupture? How do you differentiate it from a tension pneumo? - ANS- Only 20% of thoracic aortic ruptures live long enough to reach the hospital. At the hospital, their vital signs will be unstable tachycardia, hypotension. On chest xray, there should be widened mediastinum, depression of main stem bronchus and dullness to percussion of lung (due to hemothorax) How do you differentiate between central and peripheral facial nerve palsy? - ANS- Central facial nerve paralysis caused by stroke typically spares the forehead. Whereas peripheral facial nerve palsy (commonly caused by lyme or HSV) is characterized by ipsilateral forehead, eyelid, and lower facial muscles. It is rare that ipsalateral facial weakness caused by a stroke would only present as facial weakness without additional findings elsewhere The following medications are for what type of poisoning EDTA Dimercaprol Physostigmine Deferoxamine - ANS- EDTA is used to treat acute lead poisoning, which causes constipation rather than diarrhea. Additionally, patients usually have additional signs and symptoms, including headache, seizures, muscle weakness, and paresthesias. Dimercaprol chelates several heavy metals, including arsenic, to form more stable, nontoxic, soluble compounds that are then excreted in the urine. Physostigmine is used to treat anticholinergic poisoning Deferoxamine is used to treat acute iron toxicity, which also causes gastrointestinal symptoms (e.g., abdominal pain, nausea, hematemesis, diarrhea) within 6 hours of ingestion What is an easy way to reduce intracranial pressure? - ANS- Cerebral perfusion is regulated by pCO2 and patients with raised intracranial pressure who are mechanically ventilated can be managed with therapeutic hyperventilation. Hyperventilation leads to a reduction in the partial pressure of carbon dioxide (pCO2) which leads to vasoconstriction with subsequent reduction in cerebral blood flow and fall in intracranial pressure What is the moa of bisphosphates? - ANS- This class of drugs inhibits osteoclast activity, which decreases bone breakdown and calcium release. In hemodynamically stable patients what is the best way to investigate vascular injury (indicated by diminished pedal pulse)? - ANS- CT angio - in those with sufficient renal function duplex ultrasound - for those with poor renal function What is the first line treatment for wet gangrene? - ANS- emergency amputation and debridement of necrotic tissue. do not require imaging of the foot before moving forward with amputation Of the following medications, what is their mechanism of action and scenario in which they are used? (1) flumazenil (2) dantrolene (3) octreotide (4) cyproheptadine (5) benztropine - ANS- (1) flumazenil - GABA antagonist. benzo overdose (2) dantrolene - ryanodine receptor antogonist, malignant hyperthermia (3) octreotide - somatostatin analog used in carcinoid syndrome (4) cyproheptadine - first-generation H1 antihistamine with nonselective antiserotonergic activity used in serotonin syndrome (5) benztropine - muscurinic antagonist used in the treatment of extrapyramidal symptoms and neuroleptic malignant syndrome