Emergency Test Questions with Answers Graded A+
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? - Ans -Open reduction and internal fixation
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 can range from a mild sprain to severe dislocations with
fracture. Lisfranc injuries are more common in males and in the third decade
of life. 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. Anteroposterior, lateral, and oblique
radiographs are first line imaging. Stress radiographs may be necessary if non-
weight bearing radiographs are unremarkable and there is high suspicion.
Radiographic findings may include disruption of second metatarsal, avulsion
fragments, or malalignment of the fourth metatarsal and the cuboid bone.
Nonoperative management is indicated in patients with no displacement on
stress radiographs and no evidence of bony injury. Operative management is
indicated in patients with any evidence of instability or fracture. Posttraumatic
arthritis is the most common complication of Lisfranc injuries.
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,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? - Ans -Amoxicillin-clavulanate
The girl has a soft tissue infection from a cat bite. Clinical soft tissue
infections with Pasteurella multocida usually occur after cat bites, cat
scratches, or dog bites but may also occur following cat or dog licks of non-
intact skin. P. multocida wound infections characteristically have a very rapid
development of an intense inflammatory response. 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 is the first organism to consider in
any patient who presents with a soft tissue infection following cat scratches or
cat or dog bites or licks. The diagnosis of P. multocida infection is made by
isolation of the organism in culture. Pasteurella sp., including P. multocida,
are usually susceptible to a number of antibiotics, including amoxicillin-
clavulanate, piperacillin-tazobactam, doxycycline, fluoroquinolones,
advanced cephalosporins, and carbapenems.
Which of the following is most likely to be associated with a bilateral
interfacetal dislocation? - Ans -complete cord transection
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Page
,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 injury involves
forceful disruption of multiple structures at the level of the injury, including all
ligamentous structures, the articular facet joints, and the intervertebral disc.
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 19-year-old migrant worker 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? - Ans -
decontamination
This patient is exhibiting signs and symptoms consistent with cholinergic
toxicity secondary to organophosphate poisoning. Management of
organophosphate poisoning should begin with decontamination. Anyone
coming into contact with the patient should wear a gown and gloves to
prevent transmission of the toxin. Clothing should be removed and discarded
in a well-ventilated area and the patient should be thoroughly washed
including ocular irrigation. The patient should then be resuscitated in a similar
manner to any other ED patient. These patients often require early intubation
and aggressive IV fluid resuscitation. 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
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secretions. Pralidoxime (2-PAM) is the definitive antidote to organophosphate
, poisoning. 2-PAM forms a complex with the bound acetylcholinesterase
enzyme to cause the release of the organophosphate from the enzyme. This
results in regeneration of its ability to metabolize acetylcholine.
Organophosphates bind tightly to acetylcholinesterase preventing the
breakdown of acetylcholine. Signs and symptoms of organophosphate
poisoning relate to excess acetylcholine at the nicotinic and muscarinic
receptors. This produces the cholinergic toxidrome due to high postsynaptic
parasympathetic activity, resulting in the classic 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 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? - Ans -intramuscular epinephrine
This woman's presentation is concerning for anaphylaxis. 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. Anaphylaxis occurs as a result of
IgE-mediated hypersensitivity that causes mast cell degranulation and
histamine release. 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
4
Page
allergen, instead presenting following the subsequent exposures.
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? - Ans -Open reduction and internal fixation
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 can range from a mild sprain to severe dislocations with
fracture. Lisfranc injuries are more common in males and in the third decade
of life. 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. Anteroposterior, lateral, and oblique
radiographs are first line imaging. Stress radiographs may be necessary if non-
weight bearing radiographs are unremarkable and there is high suspicion.
Radiographic findings may include disruption of second metatarsal, avulsion
fragments, or malalignment of the fourth metatarsal and the cuboid bone.
Nonoperative management is indicated in patients with no displacement on
stress radiographs and no evidence of bony injury. Operative management is
indicated in patients with any evidence of instability or fracture. Posttraumatic
arthritis is the most common complication of Lisfranc injuries.
1
Page
,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? - Ans -Amoxicillin-clavulanate
The girl has a soft tissue infection from a cat bite. Clinical soft tissue
infections with Pasteurella multocida usually occur after cat bites, cat
scratches, or dog bites but may also occur following cat or dog licks of non-
intact skin. P. multocida wound infections characteristically have a very rapid
development of an intense inflammatory response. 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 is the first organism to consider in
any patient who presents with a soft tissue infection following cat scratches or
cat or dog bites or licks. The diagnosis of P. multocida infection is made by
isolation of the organism in culture. Pasteurella sp., including P. multocida,
are usually susceptible to a number of antibiotics, including amoxicillin-
clavulanate, piperacillin-tazobactam, doxycycline, fluoroquinolones,
advanced cephalosporins, and carbapenems.
Which of the following is most likely to be associated with a bilateral
interfacetal dislocation? - Ans -complete cord transection
2
Page
,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 injury involves
forceful disruption of multiple structures at the level of the injury, including all
ligamentous structures, the articular facet joints, and the intervertebral disc.
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 19-year-old migrant worker 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? - Ans -
decontamination
This patient is exhibiting signs and symptoms consistent with cholinergic
toxicity secondary to organophosphate poisoning. Management of
organophosphate poisoning should begin with decontamination. Anyone
coming into contact with the patient should wear a gown and gloves to
prevent transmission of the toxin. Clothing should be removed and discarded
in a well-ventilated area and the patient should be thoroughly washed
including ocular irrigation. The patient should then be resuscitated in a similar
manner to any other ED patient. These patients often require early intubation
and aggressive IV fluid resuscitation. 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
3
Page
secretions. Pralidoxime (2-PAM) is the definitive antidote to organophosphate
, poisoning. 2-PAM forms a complex with the bound acetylcholinesterase
enzyme to cause the release of the organophosphate from the enzyme. This
results in regeneration of its ability to metabolize acetylcholine.
Organophosphates bind tightly to acetylcholinesterase preventing the
breakdown of acetylcholine. Signs and symptoms of organophosphate
poisoning relate to excess acetylcholine at the nicotinic and muscarinic
receptors. This produces the cholinergic toxidrome due to high postsynaptic
parasympathetic activity, resulting in the classic 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 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? - Ans -intramuscular epinephrine
This woman's presentation is concerning for anaphylaxis. 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. Anaphylaxis occurs as a result of
IgE-mediated hypersensitivity that causes mast cell degranulation and
histamine release. 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
4
Page
allergen, instead presenting following the subsequent exposures.
