ABEM Oral Board Critical Actions and Pearls (Questions with Ready Answers) 2024

ABEM Oral Board Critical Actions and Pearls (Questions with Ready Answers) 2024 55-year-old with abrupt-onset mid-to-lower left-sided back pain for hours, up the chest and down the leg. Smokes. 165 over 90, heart rate 90. 98%. Good pulses. Normal EKG, chest x-ray, and troponin. Abnormal CT. Initially better, now worsening after meds. 6 CRITICAL ACTIONS? - CORRECT ANSWER-EKG. (Should also place on cardiac monitor) Chest film, then CT scan. Don't forget: Pain control (type and crossmatch 8 units). Pulses and neurologic exam. (Ask about smoking history) Discussion of differential diagnosis with radiologist or ICU. Admission to ICU. (Should also notify primary care doctor) Blood pressure control with esmolol, then I.V. nitroprusside. (Should also control heart rate) Only indication for specialist consult - CORRECT ANSWER-Management that cannot be performed by ED physician. They cannot provide opinion or help with work-up. 22-year-old female who took half bottle (about 15 325 milligram tablets per EMS) of ferrous sulfate 4 hours ago, now having scant hematemesis, diarrhea, and epigastric pain/tenderness. Tachycardic (96). Still vomiting. Serum iron level 666. 5 CRITICAL ACTIONS? - CORRECT ANSWER-Large-bore I.V. and fluid bolus. (Also urine pregnancy test) EKG. Don't Forget: WHOLE BOWEL IRRIGATION after N.G. tube placement. (Consider Reglan instead of Zofran) Don't forget: Deferoxamine 5mL/kg per hour. (Also consult poison center and psychiatry) Aspirin and acetaminophen levels. (Should check LFTs, serum iron level) Activated charcoal is ineffective against these three categories of toxins - CORRECT ANSWER-Alcohols. Charged substances (metals and electrolytes). And acids or bases. Percentage of elemental iron in Ferrous Sulfate - CORRECT ANSWER-20% (>20 mg/kg = toxic dose). When you check a level, anything over 1000 is severe. 3-week-old with progressively worsening projectile (streaked with blood) vomiting during feeds for 3 days. Fewer wet diapers. Turning yellow. Heart rate 170. Systolic pressure 50. 2.8 kilograms. Appears hungry. Weak cry, poor skin elasticity, slow capillary refill. Potassium 2.9. 4 CRITICAL ACTIONS? - CORRECT ANSWER-Abdominal exam. I.V. access and fluids (may require IO line). Don't forget: N.G. tube and N.P.O. status for vomiting. Abdominal ultrasound. Elderly female. While being assisted to bathroom, collapsed with some twitching, still verbal, started complaining of shortness of breath. Low GCS. Takes warfarin for chronic atrial fibrillation. 80% on room air. Pinpoint pupils and agonal respiratory rate of 6. Slight gurgling. No gag. Worsening bradycardia and hypertension. EKG shows bradycardia with lateral T-wave inversions. Abnormal C.T. 8 CRITICAL ACTIONS? - CORRECT ANSWER-Check glucose. Intubate, large-bore I.V. access. (Consider monitor with continuous pulse oximetry and end-tidal, naloxone, D-dimer and ECG for hypoxia) Fluids. INR. (Check aspirin and acetaminophen levels) Don't forget: A.B.G. Head C.T. (Consider CXR for hypoxia) Vitamin K. Consider F.F.P. or P.C.C. Neurosurgery and I.C.U. consultation. Young male stabbed in chest with severe difficulty breathing (tracheal deviation with distended neck veins). Hypotensive, tachycardic. 92% on non-rebreather mask. Almost febrile. Intoxicated. 5 CRITICAL ACTIONS? - CORRECT ANSWER-Tube thoracostomy (consider needle first). Can ultrasound to exclude pericardial tamponade first. *Upright* chest film. (Only once after thoracostomy) Pain control. (IV, monitor, continuous pulse oximetry, fluids, and tetanus toxoid IM) Full body survey for other injuries. Consult surgery. 43-year-old female with right upper quadrant abdominal pain, vomiting, and fever. 4 CRITICAL ACTIONS? - CORRECT ANSWER-Large-bore I.V. Right upper quadrant ultrasound (consider chest film and EKG as well) Pain medications and antibiotics. Consult surgery. (Consider pre-operative PT/PTT and type and hold as well as urine pregnancy test) 4-week-old with fever, lethargy. Hypoxia, hypotension with tachycardia. 4 CRITICAL ACTIONS? - CORRECT ANSWER-Intravenous or intra-osseous access. (Check POC glucose, CBC, blood cultures, UA, and LP) 20 mL/kg, up to 4 times. (Anytime you give oxygen, get a chest film) Antibiotics early.