BCEMP Practice Exam questions well
answers graded A+
A) Etomidate 20 mg and rocuronium 80 mg
Etomidate dosing for RSI is typically 0.3 mg/kg but may fall within a range of approximately 0.2-
0.6 mg/kg. A 20-mg dose of etomidate is slightly less than 0.3 mg/kg for this 70-kg patient and
would be appropriate to use. Rocuronium dosing for RSI is typically 1-1.2 mg/kg for adults, so 80
mg (i.e., 1.1 mg/kg for this 70-kg patient) would be appropriate to use. The use of
succinylcholine is contraindicated in patients with hyperkalemia. JD's history of ESRD with two
recently missed dialysis sessions increases his risk of hyperkalemia. Because a serum potassium
concentration measurement is not available for JD, succinylcholine use should be avoided. -
correct answer ✔✔JD is a 65-year-old male presenting to the emergency department (ED) via
emergency medical services (EMS) transport from home for shortness of breath and difficulty
breathing. His wife reports that JD's condition has progressively worsened over the past 12
hours, he has become more altered, and he is difficult to arouse. The EMS staff report an initial
oxygen saturation (SpO2) of 74%. His vital signs on arrival at the ED are BP 178/109 mm Hg, HR
105 bpm, SpO2 97% on non-rebreather mask, and temp 37.1°C. JD is currently unarousable by
voice and noxious stimuli. The only available past medical history is chronic obstructive
pulmonary disease (COPD) secondary to cigarette smoking and end-stage renal disease (ESRD)
from an unknown cause. He is on dialysis but has missed his last two dialysis sessions. The
medical team is preparing for intubation and asks for rapid sequence induction (RSI)
medications to be drawn up for a
A) Epinephrine should be kept available by override because of the need for rapid access to the
drug and potential for respiratory or cardiac arrest within minutes if prompt treatment is not
provided.
Anaphylaxis is a medical emergency with a potential for severe complications and death, which
can occur within minutes without prompt treatment. Rapid access to and administration of
epinephrine are paramount. Epinephrine should be stored in the ADCs in the ED and kept
available by override due to its life-saving potential. Although there is risk of dosing errors due
,to the availability of multiple concentrations and inappropriate routes of administration, this
risk is outweighed by the potential benefit in this medical emergency. - correct answer ✔✔The
pharmacy leadership at your institution is currently considering changes to the automated
dispensing cabinet (ADC) workflow. Currently, all medications stored in ADCs in the emergency
department (ED) are available "on override" (i.e., access may be gained by overriding system
prompts for authorization). Your input about whether to allow overrides for medications stored
in the ADCs used specifically to treat anaphylaxis in the ED has been solicited. Which of the
following is the most appropriate response?
A) Epinephrine should be kept available by override because of the need for rapid access to the
drug and potential for respiratory or cardiac arrest within minutes if prompt treatment is not
provided.
B) Epinephrine should be removed from override because of the multiple available
concentrations and routes of administration, which could contribute to medication errors.
C) Methylprednisolone should be kept availa
D) Administer a crystalloid IV fluid bolus immediately followed by post-intubation analgesia and
sedation.
This patient is hypotensive immediately post-intubation, which could be due to numerous
factors, including but not limited to recent use of sedative induction agents, critical illness, and
positive pressure ventilation secondary to invasive mechanical ventilation. The patient's mean
arterial pressure (MAP) is less than 65 mm Hg (calculated by doubling the diastolic blood
pressure of 48 mm Hg, adding the systolic blood pressure of 81 mm Hg, and dividing the result
by 3 = 59 mm Hg), so treatment is appropriate. In most patients, the first-line treatment for
hypotension or undifferentiated shock is volume resuscitation with IV crystalloid fluids. It is
common for certain analgesics and sedatives to contribute to negative hemodynamic effects,
including lowering of blood pressure and heart rate. Nevertheless, the us - correct answer
✔✔MR is a 44-year-old female who presented to the emergency department in acute
respiratory distress with hypoxia. She was subsequently intubated using etomidate and
rocuronium for impending respiratory failure and worsening mental status approximately 5
minutes ago. Based on X-ray imaging results and the history of present illness, the treatment
team believes this patient's condition is most likely the result of a viral respiratory illness. Prior
to intubation, MR's blood pressure was 155/102 mm Hg and heart rate was 105 bpm. Her
,current blood pressure is 81/48 mm Hg and heart rate is 116 bpm. Which of the following
strategies is most appropriate to address this patient's acute blood pressure change and post-
intubation management needs?
A) Initiate a norepinephrine IV infusion but do not initiate post-intubation analgesia and
sedation until the blood pressure normalizes.
B) Initiate a norepinephrine IV infusion immed
A) Type I
Type I immunologic drug reactions are mediated by IgE pathways and occur immediately. They
contribute to rash, urticaria, angioedema, shortness of breath, nausea, vomiting, wheezing, and
anaphylaxis. HM is experiencing some of these symptoms currently, so the most likely Gell and
Coombs classification is Type I. - correct answer ✔✔HM is a 35-year-old female recently
diagnosed with a urinary tract infection by her primary care provider.
Sulfamethoxazole/trimethoprim 800 mg/160 mg orally twice daily was prescribed by her
primary care provider. Approximately 15 minutes after taking her first dose, HM developed a
diffuse rash, urticaria, and wheezing. Her husband called 9-1-1 for help and while paramedics
were loading HM into the ambulance for transport, she had two episodes of vomiting. Based on
the Gell and Coombs classification, which of the following categories of immunologic drug
reactions is HM experiencing?
A) Type I
B) Type II
C) Type III
D) Type IV
B) Glucagon 3 mg by slow IV push
HM probably is experiencing anaphylaxis. The initial recommended treatment is epinephrine
0.3-0.5 mg IM in adults with the anterolateral aspect of the thigh used as the preferred site.
, HM's condition is continuing to deteriorate despite receiving two 0.3-mg IM doses of
epinephrine. Alternative therapies are recommended for patients with refractory anaphylaxis.
Intravenous glucagon is among these alternatives. This patient has been taking metoprolol
succinate, and it may be blunting the activity of epinephrine. Glucagon's mechanism involves
agonism of glucagon-specific G-protein coupled receptors in a multitude of cells, which activates
adenylyl cyclase resulting in increased cyclic AMP. These effects can mimic those of beta-
agonists, such as epinephrine, without activating the adrenergic receptor. The use of glucagon
has been proposed in cases of anaphylaxis unresponsive to epinephri - correct answer ✔✔HM,
the 35-year-old female recently diagnosed with a urinary tract infection who experienced a
reaction to sulfamethoxazole/trimethoprim at home, presents to the emergency department
(ED) via ambulance approximately 10 minutes after paramedics arrived on the scene. She
received two 0.3-mg intramuscular (IM) doses of epinephrine in the anterolateral aspect of her
thigh during transport with the last dose given 3 minutes ago. The emergency medical services
staff were able to obtain peripheral intravenous (IV) access prior to arrival at the ED. On initial
evaluation in the ED, HM has a diffuse rash and urticaria that worsened during transport. She
has audible wheezes and reports that her throat feels like it is closing. Her only reported past
medical history includes paroxysmal atrial tachycardia diagnosed 10 years ago for which she
takes metoprolol succinate 50 mg orally daily. As the emergency medicine team is prepari
C) Decreased time to sedative and analgesic administration
Multiple studies have demonstrated that EM pharmacist involvement can decrease the time to
sedative and analgesic administration in patients undergoing intubation. A reduction also has
been demonstrated in the percentage of patients who are managed without analgesia, which
improves compliance with pain, agitation/sedation, delirium, immobility, and sleep disruption
(PADIS) guideline recommendations for the use of analgesia-based backbones or
analgosedation for post-intubation management. However, the demonstrated benefits from EM
pharmacist involvement do not include reduced hospital length of stay, duration of mechanical
ventilation (i.e., time to extubation), or mortality. - correct answer ✔✔Your pharmacy and
emergency departments are planning to provide emergency medicine (EM) pharmacy services
for the first time. As part of this endeavor, the institution is evaluating its priorities for EM
pharmacist response. The institution plans to collect data for EM pharmacist involvement during
intubations. Based on currently available literature, which of the following is the most likely
benefit from an EM pharmacist's involvement in intubations and post-intubation management?
answers graded A+
A) Etomidate 20 mg and rocuronium 80 mg
Etomidate dosing for RSI is typically 0.3 mg/kg but may fall within a range of approximately 0.2-
0.6 mg/kg. A 20-mg dose of etomidate is slightly less than 0.3 mg/kg for this 70-kg patient and
would be appropriate to use. Rocuronium dosing for RSI is typically 1-1.2 mg/kg for adults, so 80
mg (i.e., 1.1 mg/kg for this 70-kg patient) would be appropriate to use. The use of
succinylcholine is contraindicated in patients with hyperkalemia. JD's history of ESRD with two
recently missed dialysis sessions increases his risk of hyperkalemia. Because a serum potassium
concentration measurement is not available for JD, succinylcholine use should be avoided. -
correct answer ✔✔JD is a 65-year-old male presenting to the emergency department (ED) via
emergency medical services (EMS) transport from home for shortness of breath and difficulty
breathing. His wife reports that JD's condition has progressively worsened over the past 12
hours, he has become more altered, and he is difficult to arouse. The EMS staff report an initial
oxygen saturation (SpO2) of 74%. His vital signs on arrival at the ED are BP 178/109 mm Hg, HR
105 bpm, SpO2 97% on non-rebreather mask, and temp 37.1°C. JD is currently unarousable by
voice and noxious stimuli. The only available past medical history is chronic obstructive
pulmonary disease (COPD) secondary to cigarette smoking and end-stage renal disease (ESRD)
from an unknown cause. He is on dialysis but has missed his last two dialysis sessions. The
medical team is preparing for intubation and asks for rapid sequence induction (RSI)
medications to be drawn up for a
A) Epinephrine should be kept available by override because of the need for rapid access to the
drug and potential for respiratory or cardiac arrest within minutes if prompt treatment is not
provided.
Anaphylaxis is a medical emergency with a potential for severe complications and death, which
can occur within minutes without prompt treatment. Rapid access to and administration of
epinephrine are paramount. Epinephrine should be stored in the ADCs in the ED and kept
available by override due to its life-saving potential. Although there is risk of dosing errors due
,to the availability of multiple concentrations and inappropriate routes of administration, this
risk is outweighed by the potential benefit in this medical emergency. - correct answer ✔✔The
pharmacy leadership at your institution is currently considering changes to the automated
dispensing cabinet (ADC) workflow. Currently, all medications stored in ADCs in the emergency
department (ED) are available "on override" (i.e., access may be gained by overriding system
prompts for authorization). Your input about whether to allow overrides for medications stored
in the ADCs used specifically to treat anaphylaxis in the ED has been solicited. Which of the
following is the most appropriate response?
A) Epinephrine should be kept available by override because of the need for rapid access to the
drug and potential for respiratory or cardiac arrest within minutes if prompt treatment is not
provided.
B) Epinephrine should be removed from override because of the multiple available
concentrations and routes of administration, which could contribute to medication errors.
C) Methylprednisolone should be kept availa
D) Administer a crystalloid IV fluid bolus immediately followed by post-intubation analgesia and
sedation.
This patient is hypotensive immediately post-intubation, which could be due to numerous
factors, including but not limited to recent use of sedative induction agents, critical illness, and
positive pressure ventilation secondary to invasive mechanical ventilation. The patient's mean
arterial pressure (MAP) is less than 65 mm Hg (calculated by doubling the diastolic blood
pressure of 48 mm Hg, adding the systolic blood pressure of 81 mm Hg, and dividing the result
by 3 = 59 mm Hg), so treatment is appropriate. In most patients, the first-line treatment for
hypotension or undifferentiated shock is volume resuscitation with IV crystalloid fluids. It is
common for certain analgesics and sedatives to contribute to negative hemodynamic effects,
including lowering of blood pressure and heart rate. Nevertheless, the us - correct answer
✔✔MR is a 44-year-old female who presented to the emergency department in acute
respiratory distress with hypoxia. She was subsequently intubated using etomidate and
rocuronium for impending respiratory failure and worsening mental status approximately 5
minutes ago. Based on X-ray imaging results and the history of present illness, the treatment
team believes this patient's condition is most likely the result of a viral respiratory illness. Prior
to intubation, MR's blood pressure was 155/102 mm Hg and heart rate was 105 bpm. Her
,current blood pressure is 81/48 mm Hg and heart rate is 116 bpm. Which of the following
strategies is most appropriate to address this patient's acute blood pressure change and post-
intubation management needs?
A) Initiate a norepinephrine IV infusion but do not initiate post-intubation analgesia and
sedation until the blood pressure normalizes.
B) Initiate a norepinephrine IV infusion immed
A) Type I
Type I immunologic drug reactions are mediated by IgE pathways and occur immediately. They
contribute to rash, urticaria, angioedema, shortness of breath, nausea, vomiting, wheezing, and
anaphylaxis. HM is experiencing some of these symptoms currently, so the most likely Gell and
Coombs classification is Type I. - correct answer ✔✔HM is a 35-year-old female recently
diagnosed with a urinary tract infection by her primary care provider.
Sulfamethoxazole/trimethoprim 800 mg/160 mg orally twice daily was prescribed by her
primary care provider. Approximately 15 minutes after taking her first dose, HM developed a
diffuse rash, urticaria, and wheezing. Her husband called 9-1-1 for help and while paramedics
were loading HM into the ambulance for transport, she had two episodes of vomiting. Based on
the Gell and Coombs classification, which of the following categories of immunologic drug
reactions is HM experiencing?
A) Type I
B) Type II
C) Type III
D) Type IV
B) Glucagon 3 mg by slow IV push
HM probably is experiencing anaphylaxis. The initial recommended treatment is epinephrine
0.3-0.5 mg IM in adults with the anterolateral aspect of the thigh used as the preferred site.
, HM's condition is continuing to deteriorate despite receiving two 0.3-mg IM doses of
epinephrine. Alternative therapies are recommended for patients with refractory anaphylaxis.
Intravenous glucagon is among these alternatives. This patient has been taking metoprolol
succinate, and it may be blunting the activity of epinephrine. Glucagon's mechanism involves
agonism of glucagon-specific G-protein coupled receptors in a multitude of cells, which activates
adenylyl cyclase resulting in increased cyclic AMP. These effects can mimic those of beta-
agonists, such as epinephrine, without activating the adrenergic receptor. The use of glucagon
has been proposed in cases of anaphylaxis unresponsive to epinephri - correct answer ✔✔HM,
the 35-year-old female recently diagnosed with a urinary tract infection who experienced a
reaction to sulfamethoxazole/trimethoprim at home, presents to the emergency department
(ED) via ambulance approximately 10 minutes after paramedics arrived on the scene. She
received two 0.3-mg intramuscular (IM) doses of epinephrine in the anterolateral aspect of her
thigh during transport with the last dose given 3 minutes ago. The emergency medical services
staff were able to obtain peripheral intravenous (IV) access prior to arrival at the ED. On initial
evaluation in the ED, HM has a diffuse rash and urticaria that worsened during transport. She
has audible wheezes and reports that her throat feels like it is closing. Her only reported past
medical history includes paroxysmal atrial tachycardia diagnosed 10 years ago for which she
takes metoprolol succinate 50 mg orally daily. As the emergency medicine team is prepari
C) Decreased time to sedative and analgesic administration
Multiple studies have demonstrated that EM pharmacist involvement can decrease the time to
sedative and analgesic administration in patients undergoing intubation. A reduction also has
been demonstrated in the percentage of patients who are managed without analgesia, which
improves compliance with pain, agitation/sedation, delirium, immobility, and sleep disruption
(PADIS) guideline recommendations for the use of analgesia-based backbones or
analgosedation for post-intubation management. However, the demonstrated benefits from EM
pharmacist involvement do not include reduced hospital length of stay, duration of mechanical
ventilation (i.e., time to extubation), or mortality. - correct answer ✔✔Your pharmacy and
emergency departments are planning to provide emergency medicine (EM) pharmacy services
for the first time. As part of this endeavor, the institution is evaluating its priorities for EM
pharmacist response. The institution plans to collect data for EM pharmacist involvement during
intubations. Based on currently available literature, which of the following is the most likely
benefit from an EM pharmacist's involvement in intubations and post-intubation management?
