Emergency Exam Questions With Complete Solutions
*aortic disruption* Correct Answer rapid decelerations injury
usually fatal, most who live have hematoma w/in adventitia
laceration MC just proximal to ligament arteriosum
upper extremity HTN, hoarse and quiet voice from impingement
of recurrent laryngeal nerve
CXR reveals widened mediastinum, loss of aortic knob, pleural
cap, tracheal deviation, L mainstem bronchus depression
a new diastolic murmur after chest trauma Correct Answer
aortic dissection
abdominal aortic aneurysm dx Correct Answer abdominal
ultrasound: initial imaging study of choice in suspected AAA to
determine aneurysm presence, size, and extent. also used to
monitor for progression in size (expansion). bedside US often
done in ER to r/o AAA in pts presenting w/ nonspecific
abdominal pain >60y
CT scan: test of choice for thoracic aneurysms and for further
evaluation in pts w/ known AAA
angiography: gold standard, often used before surgical
intervention
MRI/MRA: increased use in lieu of angiography
,abdominal radiography: may show calcified aorta in 65% of pts
w/ aneurysmal disease
abdominal aortic aneurysm pathophys Correct Answer
proteolytic degeneration of the aortic wall, connective tissue
inflammation and an immune response
laplace's law: wall tension -- (pressure x radius)/tensile force
dictates that as the aorta dilates --> the force on the aortic wall
increases --> further dilation (larger aneurysms expand more
quickly)
-avg rate 0.25-0.5cm/yr. all expanding aneurysms will
eventually rupture
focal dilation of the aortic diameter at least 1-1.5x diameter
measured at level of the renal arteries
abdominal aortic aneurysm RFs Correct Answer
atherosclerosis
age >60y
smoking
males (5x MC in men), caucasians
hyperlipidemia, connective tissue disorder (marfans), syphilis,
HTN
abdominal aortic aneurysm sx Correct Answer most
asymptomatic until they rupture. often incidental finding on US,
CT, or MRI when doing workup for other problems or on PE
(palpable, expanding, pulsatile abdominal mass)
,acute leakage/rupture: classic presentation -- older male w/
severe back or abdominal pain who presents w/ syncope or
hypotension and tender, pulsatile, abdominal mass. may be
obscured by obesity. may complain of unilateral groin/hip pain.
+/- flank ecchymosis. femoral pulsations usually normal. acute
may be rapidly fatal. >5cm = increased rupture risk
chronic-contained rupture: uncommon. rupture may be
tamponade by surrounding retroperitoneum
aortoenteric fistula: presents as acute GI bleed in pts who
underwent prior aortic grafting
abdominal aortic aneurysm tx Correct Answer surgical repair
definitive tx. endovascular stent graft or open repair
>5.5cm or >0.5cm expansion in 6mo -- immediate surgical
repair (even if asymptomatic), symptomatic pts or pts w/ acute
rupture
>4.5cm -- vascular surgeon referral
4-4.5cm -- monitor by US q6mo
3-4cm -- monitor by US qyear
beta-blockers reduces shearing forces, increases expansion and
rupture risk. decreases RFs
absence (petit mal) seizure Correct Answer diffuse brain
involvement. brief lapse of consciousness -- pt usually unaware
, of attacks. brief staring episodes, eyelid twitching, no post-ictal
phase
may be clonic (jerking), tonic (stiffness), or atonic (loss of
postural tone). MC in childhood --> usually ceases by 20y
EEG: bilateral symmetric 3Hz spike and wave action or may be
normal
ACS tx Correct Answer 2 part approach: antithrombin therapy
and adjunctive therapy/assess risk factors w/ TIMI score
antithrombin therapy: anti-platelet drugs (aspirin, ADP
inhibitors, GP IIb/IIIa inhibitors) and anticoagulants
(unfractionated heparin, low molecular weight heparin,
fondaparinux)
adjunctive therapy: beta-blockers (metoprolol), nitrates,
morphine, ca channel blockers (nondihydropyridines verapamil
and diltiazem, and dihydropyridines)
acute coronary syndrome dx Correct Answer NSTEMI or
unstable angina: +/- ST depressions and/or T wave inversions.
EKG may be normal
STEMI: ST elevations >1mm in >2 anatomically contiguous
leads +/- reciprocal changes in the opposite leads. a new left
bundle branch block is a STEMI equivalent
hyperacute (peaked) T waves --> ST elevations --> Q waves -->
T wave inversions is natural STEMI progression
*aortic disruption* Correct Answer rapid decelerations injury
usually fatal, most who live have hematoma w/in adventitia
laceration MC just proximal to ligament arteriosum
upper extremity HTN, hoarse and quiet voice from impingement
of recurrent laryngeal nerve
CXR reveals widened mediastinum, loss of aortic knob, pleural
cap, tracheal deviation, L mainstem bronchus depression
a new diastolic murmur after chest trauma Correct Answer
aortic dissection
abdominal aortic aneurysm dx Correct Answer abdominal
ultrasound: initial imaging study of choice in suspected AAA to
determine aneurysm presence, size, and extent. also used to
monitor for progression in size (expansion). bedside US often
done in ER to r/o AAA in pts presenting w/ nonspecific
abdominal pain >60y
CT scan: test of choice for thoracic aneurysms and for further
evaluation in pts w/ known AAA
angiography: gold standard, often used before surgical
intervention
MRI/MRA: increased use in lieu of angiography
,abdominal radiography: may show calcified aorta in 65% of pts
w/ aneurysmal disease
abdominal aortic aneurysm pathophys Correct Answer
proteolytic degeneration of the aortic wall, connective tissue
inflammation and an immune response
laplace's law: wall tension -- (pressure x radius)/tensile force
dictates that as the aorta dilates --> the force on the aortic wall
increases --> further dilation (larger aneurysms expand more
quickly)
-avg rate 0.25-0.5cm/yr. all expanding aneurysms will
eventually rupture
focal dilation of the aortic diameter at least 1-1.5x diameter
measured at level of the renal arteries
abdominal aortic aneurysm RFs Correct Answer
atherosclerosis
age >60y
smoking
males (5x MC in men), caucasians
hyperlipidemia, connective tissue disorder (marfans), syphilis,
HTN
abdominal aortic aneurysm sx Correct Answer most
asymptomatic until they rupture. often incidental finding on US,
CT, or MRI when doing workup for other problems or on PE
(palpable, expanding, pulsatile abdominal mass)
,acute leakage/rupture: classic presentation -- older male w/
severe back or abdominal pain who presents w/ syncope or
hypotension and tender, pulsatile, abdominal mass. may be
obscured by obesity. may complain of unilateral groin/hip pain.
+/- flank ecchymosis. femoral pulsations usually normal. acute
may be rapidly fatal. >5cm = increased rupture risk
chronic-contained rupture: uncommon. rupture may be
tamponade by surrounding retroperitoneum
aortoenteric fistula: presents as acute GI bleed in pts who
underwent prior aortic grafting
abdominal aortic aneurysm tx Correct Answer surgical repair
definitive tx. endovascular stent graft or open repair
>5.5cm or >0.5cm expansion in 6mo -- immediate surgical
repair (even if asymptomatic), symptomatic pts or pts w/ acute
rupture
>4.5cm -- vascular surgeon referral
4-4.5cm -- monitor by US q6mo
3-4cm -- monitor by US qyear
beta-blockers reduces shearing forces, increases expansion and
rupture risk. decreases RFs
absence (petit mal) seizure Correct Answer diffuse brain
involvement. brief lapse of consciousness -- pt usually unaware
, of attacks. brief staring episodes, eyelid twitching, no post-ictal
phase
may be clonic (jerking), tonic (stiffness), or atonic (loss of
postural tone). MC in childhood --> usually ceases by 20y
EEG: bilateral symmetric 3Hz spike and wave action or may be
normal
ACS tx Correct Answer 2 part approach: antithrombin therapy
and adjunctive therapy/assess risk factors w/ TIMI score
antithrombin therapy: anti-platelet drugs (aspirin, ADP
inhibitors, GP IIb/IIIa inhibitors) and anticoagulants
(unfractionated heparin, low molecular weight heparin,
fondaparinux)
adjunctive therapy: beta-blockers (metoprolol), nitrates,
morphine, ca channel blockers (nondihydropyridines verapamil
and diltiazem, and dihydropyridines)
acute coronary syndrome dx Correct Answer NSTEMI or
unstable angina: +/- ST depressions and/or T wave inversions.
EKG may be normal
STEMI: ST elevations >1mm in >2 anatomically contiguous
leads +/- reciprocal changes in the opposite leads. a new left
bundle branch block is a STEMI equivalent
hyperacute (peaked) T waves --> ST elevations --> Q waves -->
T wave inversions is natural STEMI progression
