Emergency Medicine Pretest Questions and Answers, Exams of Nursing

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Emergency Medicine (Pretest) questions with

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Before giving nitroglycerin, must rule out... ans ✓✓ right ventricular infarct and cardiac tamponade What are the possible EKG manifestations of right heart strain? ans ✓✓ RAD, S1Q3T3, RBBB, Afib, peaked P in II Best med for rate control in A fib? ans ✓✓ diltiazem (great AV nodal targeting) EKG finding of hypocalcemia? ans ✓✓ long QT EKG finding of hypercalcemia? ans ✓✓ short QT Management of pneumothorax? ans ✓✓ If small (<20%) in otherwise healthy patient, observe for 6 hours and CXR before discharge Possible CXR finding of Boerhaave? ans ✓✓ lateral displacement of the left mediastinal pleura Most sensitive test for aortic dissection? ans ✓✓ TEE is best CT is second best aortogram is too invasive! Rx for cocaine chest pain? ans ✓✓ benzodiazepines (beta-blockers are contra-indicated!)

ST elevation in leads II, III, AVF? ans ✓✓ inferior infarct ST elevation in leads V1 + V2? ans ✓✓ septal infarct ST elevation in leave V3 + V4? ans ✓✓ anterior infarct ST elevation in I, AVL, V5, V6? ans ✓✓ lateral infact WPW in setting of A fib is risky for? Rx? ans ✓✓ conversion to ventricular fibrillation procainamide EKG manifestations of hyperkalemia? ans ✓✓ peaked T wave, wide QRS, no P waves How to manage stable hyperkalemia (no EKG changes)? ans ✓✓ kayexalate (binds and actually removes K, instead of just shifting it inward like insulin does) How to manage unstable hyperkalemia (+ EKG findings)? ans ✓✓ calcium gluconate Function of glucagon in endoscopy? ans ✓✓ relaxes the GE junction! Which type of effusions are exudative? ans ✓✓ malignant What qualifies as an exudative effusion? ans ✓✓ fluid-to-blood protein >0. fluid-to-blood LDH >0. LDH > Risk factor for inhalation of anthrax spores? ans ✓✓ animal hides...

When should epi be given IM versus IV? ans ✓✓ stable versus unstable CD4 count that places HIV patient at risk for PCP? ans ✓✓ < Management of suspected thermal lung burn patient? ans ✓✓ early intubation d/t high risk of pneumonitis Patient with MI, holosystolic murmur, flash pulmonary edema? ans ✓✓ papillary muscle rupture How to deactivate an activated AICD generator? ans ✓✓ use the donut magnet Patient with family history of fainting and no other risk factors? Rx? ans ✓✓ Long QT syndrome (>440ms), usually congenital (Romano-Ward is AD while Lang-Nielsen is AR with deafness). Rx for Prinzmetal's Angina? ans ✓✓ calcium channel blockers Viral cause of myocarditis in the summer months? ans ✓✓ coxsackie B Order of EKG changes in MI? ans ✓✓ hyperacute T wave, ST segment elevation, then Q wave EKG changes of pericarditis? ans ✓✓ diffuse ST elevation + PR depression Rx for SVT? ans ✓✓ adenosine (emergent) but can first try carotid massage, valsalva and immersion of face in cold water

When does appendicitis present with pain in the RUQ? ans ✓✓ retrocecal or retroiliac appendix or in pregnancy Pain prior to nausea and vomiting is suggestive of? ans ✓✓ surgical cause to abdominal pain Best test for renal calculi? ans ✓✓ CT > KUB > US Best test for hydronephrosis? ans ✓✓ US Patient with signs of bowel obstruction but without usual risk factors, usually between 25- YO? ans ✓✓ cecal volvulus chronic constipation is not a risk factor, but marathon running is! Management of elderly patient with diverticulitis? ans ✓✓ treat conservatively - always admit for IV abx, even if vital signs are normal Where do most spontaneous esophageal perfs occur? ans ✓✓ distal esophagus Where do most iatrogenic esophageal perfs occur? ans ✓✓ junctions Drug toxicity that presents with n/v/fatigue and visual disturbances + palpitations? ans ✓✓ digoxin Med toxicity that closely mimics that of opioids? ans ✓✓ clonidine (alpha 1 blocker) presents with hypotension, bradycardia, AMS, respiratory depression and miosis EKG findings of TCA overdose? ans ✓✓ QT interval prolongation

Management of caustic ingestions? ans ✓✓ Early (not late) endoscopy...longer you wait the more likely it is to perf (probably d/t scarring). Don't give ipecac or gastric lavage because you don't want to induce 2nd contact of the caustic agent with their esophagus. Don't give activated charcoal because it won't bind caustic agents anyway, and it would obscure the endoscopy results. Patient with SOB, pulse ox 100% and chocolate colored blood? Rx? Cause? ans ✓✓ methemoglobinemia give methylene blue caused by nitrites, local anesthetics, dapsone and phenazopyridine (a GU analgesic) Acid-base disturbance seen in aspirin overdose? ans ✓✓ Double effect, and both are primary! Primary respiratory alkalosis due to direct stimulation of the CNS to produce more CO2 and thus higher RR leading to respiratory alkalosis. Also primary metabolic acidosis due to actual salicylate metabolism (+anion gap acidosis). Artery occluded in inferior MI? ST elevations? ans ✓✓ RCA II, III, AVF Criteria for fibrinolytic therapy in STEMI patients? ans ✓✓ <6-12 hours since MI ≥1mm ST elevation in ≥2 contiguous leads Football player who "spears" oncoming player and has severe neck pain? What type of fracture is this? ans ✓✓ Jefferson fracture, usually associated with C2 vertebral fracture (40%) and seen in crown/head-on football injuries d/t excessive axial loading force Common vertebral injury associated with hyperflexion, usually seen in diving accidents? Associated with? ans ✓✓ teardrop fracture (d/t extreme hyperflexion as seen in diving accidents)

associated with anterior cord syndrome most severe cervical fracture sometimes causes quadriplegia What is a hangman's fracture? ans ✓✓ traumatic spondylolysis of C2, usually seen in deceleration mechanisms of MVC's (extreme hyperextension) Most effective method for relieving acute pericardial tamponade d/t penetrating trauma? ans ✓✓ ED thoracotomy Pericardiocentesis isn't good at removing clotted blood (only free fluid) so you don't wanna do that. That would be more for stable tamponade patients. Rx for avulsed tooth? ans ✓✓ Run water over it and place it directly back in its socket. 1% decreased reimplantation rate for every minute outside the socket. Best chance if done within 30 minutes. **Check for aspiration!!! Which kind of neck injury goes directly to the OR? ans ✓✓ Zone II (between angle of the mandible and cricoid cartilage). Most exposed zone. What are the three main types of facial fractures? ans ✓✓ LeFort I, II and III When should the decision be made to give a trauma patient blood? What kind of blood should be given in a trauma? ans ✓✓ Once resuscitation w/ 2 to 3 liters of crystalloid fails (but if the blood loss is obvious + major, start concomitantly with crystalloids). Preference: Fully cross matched (but takes too long, 1hr) > type-specific (unknown antibody, 30min) > type O packed cells (fastest).

When giving Type O pRBCs, you want to give O Rh+ to men and reserve O Rh- for women of childbearing age. Management of stable patient with pelvic fracture? ans ✓✓ pelvic binding garment to tamponade bleeding What are the clinical manifestations of anterior cord syndrome? ans ✓✓ bilateral paralysis below the lesion + loss of pain and temperature preservation of proprioception and vibratory function What are the clinical manifestations of central cord syndrome? ans ✓✓ lower > upper extremity paralysis lower > upper loss of pain + temperature Age threshold for automatic C-spine imaging following trauma? ans ✓✓ Age 65 by Canadian C-spine protocol Indications for thoracotomy? ans ✓✓ - 1000 - 1500 cc blood loss from chest tube

• 200 c/hr blood loss from chest tube
• hypotensive despite 2L resuscitation
• decompensation after initial response to fluid resuscitation
• increasing hemothorax on subsequent films Fastest way to lower ICP in trauma patient with blown pupil? Second line? ans ✓✓ hyperventilate to a pCO2 of 30-35 mmHg (done by temporarily reducing vasoconstriction and thus lowering cerebral blood flow) takes 30 seconds! mannitol is best osmotic agent to do this and takes 30 minutes

Drugs that can be administered through endotracheal route? ans ✓✓ NAVEL: naloxone, atropine, versed (midazolam), epinephrine, and lidocaine Management of patient with pulseless electrical activity? ans ✓✓ progress to the next if the former doesn't work:

• epi and atropine q3-5min
• calcium gluconate in case of hyperkalemia
• sodium bicarb in case of acidosis
• d50 in case of hypoglycemia Treatment for stable Mobitz I? Unstable Mobitz I? ans ✓✓ Stable - monitor. Unstable - atropine > transq > transv pacing > epi Patient on maintenance steroid therapy who is in septic shock with continued hypotension despite crystalloid resuscitation? Mgmt? ans ✓✓ adrenal crisis - give IV hydrocortisone (in patients with adrenal crisis, you'll also see hyponatremia and hyperkalemia d/t lack of aldosterone) First three steps of sepsis early goal-directed treatment? ans ✓✓ 1 - Gotta get a CVP so that you can titrate your resuscitation to 8-12 mmHg of CVP (surrogate for intravascular volume) - but don't exceed 2L while you're at it. 2 - Give pressors to achieve a MAP of >65 mmHg. 3- Get central venous O2 saturation above 70% (measured from the central venous line). The SV02 is a surrogate for tissue perfusion / cardiac output. Scrotal pain relieved by elevation? Rx? ans ✓✓ Positive Prehn sign, suggestive of epididymitis.

If <40YO, treat Gono+Chlamydia with 250mg IM ceftriaxone + 10days doxy What is the pentad of TTP? Mgmt? ans ✓✓ FAT RAms: fever, anemia, thrombocytopenia, renal failure + altered mental status Mgmt: Daily plasmapheresis until platelet counts normalize. Resistance of CAP versus HCAP? ans ✓✓ HCAP causes tend to have more resistance than CAP. Definition of HCAP? ans ✓✓ Health-care associated pneumonia is defined as the development of pneumonia in patients with recent (within 90 days) contact with the health care system, including hospitalization, outpatient dialysis, or residing in a nursing home or rehabilitation center. Definition of HAP? ans ✓✓ Hospital-acquired pneumonia is defined as the development of a new pneumonia following at least 48 to 72 hours in the hospital. It is a common cause of nosocomial infection and the most common cause of death in ICUs. Management of peritonsillar abscess? ans ✓✓ i+d, antibiotics, return in 24h Signs + symptoms of cholinergic crisis? Cause? Mgmt? ans ✓✓ SLUDGE: salivation, lacrimation, urination, defecation, gi upset, emesis happens with organophosphates (anticholinergic inhibitors) - treat with atropine and pralidoxime Overdose characterized by intermittent respiratory depression punctuated by combativeness? ans ✓✓ gamma hydroxybutyrate (GHB) Group of family members with nausea/vomiting/fatigue that resolves when away from home? ans ✓✓ suspicious for carboxyhemoglobin poisoning, more common during winter months and in large cities. should prompt fire department house check.

Overdose that causes seizures refractory to standard therapy? Mgmt? ans ✓✓ isoniazid must give pyridoxine Management of sulfonylurea overdose? ans ✓✓ octreotide and hospital admission (long- acting so they'll get recurrent hypoglycemia till it's out of their system) don't give dextrose boluses, as this will exacerbate the insulin response and send them into further rebound hypoglycemia! Activated charcoal does NOT work for? ans ✓✓ Ions, hydrocarbons, metals, alcohols and caustics. Intoxication involving ketosis without acidosis and pseudo renal failure? ans ✓✓ isopropyl alcohol poisoning Cr will be high but not BUN Drug overdose that can cause severe hyponatremia? ans ✓✓ MDMA First step in seizing patient? ans ✓✓ place in lateral decubitus position to protect airway Mgmt of hepatic encephalopathy? ans ✓✓ lactulose and neomycin Mgmt of hypertensive encephalopathy? ans ✓✓ labetalol nitroprusside if they have an art line (can cause reflex tachy)

Triad of Wernicke's encephalopathy? How does this differ from Korsakoff syndrome? ans ✓✓ confusion, ataxia and ophthalmoplegia Korsakoff occurs with the addition of confabulation and disorientation (takes a while to develop) Most common cause of painful rectal bleeding? ans ✓✓ anal fissures Most common complication of peptic ulcer disease? ans ✓✓ GI hemorrhage > perf Most commonly injured bone in FOOSH injuries? ans ✓✓ scaphoid Portion of scaphoid with most tenuous blood supply? ans ✓✓ proximal scaphoid Most commonly associated fracture occurring with anterior shoulder dislocation? ans ✓✓ fracture of the humeral head (Hill-Sach's Deformity) Management of closed fist "fight bite" injury? ans ✓✓ admission and IV antibiotics d/t risk of polymicrobial septicemia from mouth anaerobes like eikenella (synergistic effect with aerobes) make sure it's broad spectrum (penicillin + 2nd gen cephalosporins) Management of mallet finger injury? ans ✓✓ dorsal splint to immobilize DIP for 6-8 weeks! How to evaluate for flexor tenosynovitis? ans ✓✓ Kanavel Criteria: STEP - Swelling that is uniform of the entire digit, Tenderness over the flexor tendon sheath, Extension painful, Posture of the digit is flexed. Warrants hand surgery consult.

How to evaluate for DeQuervain tenosynovitis? ans ✓✓ Finkelstein test: pain on ulnar deviation of closed fist with tucked thumb Acute carpel tunnel syndrome is commonly associated with? ans ✓✓ lunate displacement Humeral fracture commonly associated with which injury? ans ✓✓ radial nerve injury resulting in wrist drop Posterior shoulder dislocation commonly associated with which injury? ans ✓✓ median and ulnar nerve injuries Management of herpetic whitlow? ans ✓✓ I+D is CONTRAINDICATED. Can give acyclovir and wrap. Mgmt of bilateral headache with brief cortical blindness? ans ✓✓ basilar headache... give sumatriptan Management of post-LP headaches? ans ✓✓ consult anesthesia for placement of blood patch, which immediately relieves the headache Contraindications for thrombolytic therapy in stroke patients? ans ✓✓ evidence of hemorrhagic stroke

4.5 hours out mild or rapidly improving stroke symptoms recent MI systolic >185, diastolic > suspicion of SAH active internal bleeding w/in 21 days bleeding diathesis

<3 mo hx of head trauma, stroke or intracranial sx <7 days LP hx intracranial hemorrhage/AV malformation witnessed seizure at stroke onset How to determine ETT size? ans ✓✓ age/4 + 3 Treatment for paraphimosis? ans ✓✓ Manual reduction, dorsal slit incision if that doesn't work Most serious complication of supracondylar fracture? ans ✓✓ Volkmann ischemic contracture (d/t compartment syndrome and subsequent damage to brachial artery and surrounding nerves) At what level is progesterone concerning for ectopic pregnancy? ans ✓✓ <5ng/mL At what bhcg level can a IUP be visualized via transvaginal ultrasound? Via abdominal ultrasound? ans ✓✓ TV: 1500 Abd: 6500 Anti D immunoglobulin doses during pregnancy for blood exposure? ans ✓✓ 50 ug in first trimester, 300 ug in third trimester Normal gallbladder wall thickness? ans ✓✓ <5 mm Management of open book pelvic fracture? ans ✓✓ straight to the radiology suite for embolization (ultrasound is not sensitive or specific for evaluating the retroperitoneal space) Normal common bile duct diameter? ans ✓✓ 7mm (n/a to post=cholx pts) by age 40, then +1mm per decade

Management of corneal abrasion? ans ✓✓ abx eye drops with pseudomonal coverage (cipro or tobramycin) + oral analgesic + tetanus prophylaxis + ophtho referral Abx with pseudomonas coverage? ans ✓✓ aminoglycoside or fluoroquinolones Appearance of corneal ulcer vs. abrasion on fluorescein test? ans ✓✓ ulcer is shaggy white infiltrate while corneal abrasion is linear deposit on fluoroscein Dendritic ulcer on the eye? ans ✓✓ herpes simplex keratitis, give topical antiviral like trifluridine Differential for subconjunctival hemorrhage? Mgmt? ans ✓✓ Hyphema (blood in the anterior chamber) - this is an emergency that can lead to increased intraocular pressure. Happens a lot in Sickle patients. Must give beta blocker and mannitol immediately to lower the pressure. Usually admit d/t rebleed probability.