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MCCQE 1 EXAM 2024/2025 WITH 100%
ACCURATE SOLUTIONS
MCCQE 1 EXAM 2024/2025 WITH 100%
ACCURATE SOLUTIONS
HERPETIC WHITLOW - Precise Answer ✔✔ Painful grouped vesicles on an erythematous base located on the distal finger Cause: Infection with HSV Treatment: Self-limiting disease Antiviral (e.g., acyclovir) may be beneficial ONYCHOCRYPTOSIS/ INGROWN NAILS - Precise Answer ✔✔ Inflammation and soft tissue hypertrophy +/− secondary infection occurring when the lateral edge of the nail plate impinges on the nail fold ONYCHOCRYPTOSIS Cause: Onychomycosis Incorrect technique of nail cutting Repetitive trauma Poor foot hygiene; poorly fitting shoes - Precise Answer ✔✔ Treatment Barrier placement between nail plate and nail fold Excision of the portion of nail plate pressing on the nail fold
+/− Antibiotics Biphasic Anaphylaxis - Precise Answer ✔✔ Recurrence of Sx 4 to 32 h (mean 10 h) after the initial episode. Occurs in up to 20% of patients and is due to the release of 2◦ mediators and the late-phase response. Protracted Anaphylaxis - Precise Answer ✔✔ Refractory Resp distress or hypotension despite appropriate medical Rx. What Saves Lives? EPI, EPI, EPI - Precise Answer ✔✔ Adults: 0.3 to 0.5 mg IM Children: 0.01 mg/kg IM I V EPI: 0.1 mg, dilute 0.1 mL 1:1,000 in 10 mL N/S Give 1 to 2 mL/min All patients presenting with signs or Sx of anaphylaxis get: - Precise Answer ✔✔ • Measures to stop any continuing Ag exposure
- Two large bore I Vs • Supplemental O
- Cardiac and O2 sat monitoring
- EPI IM or I V
- Methylprednisolone 125 mg I V
- Diphenhydramine 50 mg I V + ranitidine 50 mg I V MINOR BURNS - Precise Answer ✔✔ • cleaning with soap and water or dilute antiseptic solution. Td immunization prn topical Abx: 1%silver sulfadiazine(Dermazine) , bacitracin (Baciguent), or bacitracin/neomycin/polymyxin B (Neosporin ointment). Occlusive, clean dressings should be applied regularly. Parkland Formula - Precise Answer ✔✔ Fluid required (ml of RL) = 4 × kg body wt × TBSA
- 1/2 given in first 8 h from time of injury, 1/2 given in next 16 h Anticholinergic - Precise Answer ✔✔ Antihistamines, TCAs, phenothiazines, atropine Cholinergic - Precise Answer ✔✔ Insecticides, nerve agents, nicotine,
pilocarpine, urecholine Sympathomimetic - Precise Answer ✔✔ Cocaine, amphetamines, MDMA (ecstasy), ephedrine, theophylline Opiate/sedative - Precise Answer ✔✔ Heroin, morphine, benzodiazepines, barbiturates, meprobamate, EtOH Hallucinogens - Precise Answer ✔✔ LSD, mescaline, phencyclidine, psilocybin CVS - Precise Answer ✔✔ β-Blockers, CCBs Serotonin - Precise Answer ✔✔ MAOI, SSRI, meperidine, TCA, L- tryptophan Cellular - Precise Answer ✔✔ CO, H2S, cyanide TCAs - Precise Answer ✔✔ Amitriptyline, doxepin Simple asphyxiants - Precise Answer ✔✔ CO2, inert gases
Drugs inducing metabolic acidosis (BP usually low) - Precise Answer ✔✔ Ethanol, methanol, ethylene glycol, ASA, NSAID, tylenol Anticholinergic ''hot as a hare, dry as a bone, red as a beet, blind as a bat, and mad as a hatter''
- ↑ Temperature
- Possible ↑ HR
- Dry mucous membranes
- Erythematous
- Mydriasis
- Disoriented, agitated - Precise Answer ✔✔ • Reaching blindly for objects
- Large ODs can lead to depressive state (sedation, coma)
- ↓ bs and ↓ GI motility
- Urinary retention Sympathomimetic ''fight or flight''
- ↑ HR
- ↑ BP
- ↑ Temperature - Precise Answer ✔✔ • Wet mucous membranes
- Diaphoretic
- Erythematous
- ↑ Psychomotor activity
- Mydriasis
- Agitated, ' reved up'' Serotonin ''wet dog shakes''
- ↑ Temperature
- May be diaphoretic; shivering; fever; diarrhea - Precise Answer ✔✔ • Altered or normal mental status
- ↑ Reflexes
- ↑ Tone Cholinergic ''secreting from every orifice''/ ''wet from head to toe''
- ↓ HR • May see ↓ BP
- May see ↓ RR and Resp failure
- Diaphoretic• Lacrimation• Salivation - Precise Answer ✔✔ • Fasciculations
- Miosis common, may see mydriasis
- Altered or normal mental status
- Nausea + vomiting
- Defecation
- Urination
- Bronchorrhea Opiod or sedative/hyponotics ''depressed all over'' - Precise Answer ✔✔ • ↓ RR• ↓ HR• ↓ BP
- ↓ Temperature
- Range from stuporous/drunk to coma
- Miosis, possible nystagmus
- ↓ LOC POISON labs:
- Routine: CBC, Lytes, gluc., ASA + acetaminophen + EtOH levels, blood gas, serum Osm, ECG - Precise Answer ✔✔ • Additional tests to consider: INR/PT, LFTs, RFTs, specific drug levels, β-HCG if fertile female, urine tox screen (often unhelpful from a Tx perspective, but can identify other drug exposures) Consider AXR indications = ''CHIPES'') - Precise Answer ✔✔ ''CHIPES'' Calcium, Chloral hydrate, CCl
Heavy metals Iron Potassium Enteric-coated Salicylates Elevated AG Acidosis ''MUDPILES'' - Precise Answer ✔✔ Methanol Uremia Diabetic ketoacidosis/alcoholic ketoacidosis Paraldehyde Isoniazid, iron Lactate Ethylene glycol Salicylates Normal AG Acidosis ''HYPERCHLOREMIC'' - Precise Answer ✔✔ Usually due to ++ saline administration because of high Cl content Narrow AG
''HARDUPS'' - Precise Answer ✔✔ Hyperventilation Acetazolamide, acids, Addison disease Renal tubular acidosis Diarrhea Ureterosigmoidostomy Pancreatic fistula Saline Gastric Decontamination - Precise Answer ✔✔ General principle: ↓ absorption or ↑ excretion of ingested poisons. Generally only effective if time since exposure ≤2 h or if delayed toxicity expected. There is limited data to support most methods of gastric decontamination. Activated Carchoal may have some benefit in specific instances Enhanced Elimination - Precise Answer ✔✔ HemoDialysis or hemoperfusion as well as alkalinization of urine or diuresis are used to enhance elimination. Methanol - Precise Answer ✔✔ • Delayed presentation common (can be 6-24 h)
- OG, AG may be normal or elevated
- ↓ LOC, ataxia, stupor, lethargy, coma
- Visual complaints common: blurry vision, ↓ acuity, ''snowstorm'' perception
- CNS effects: ↓ LOC, Parkinsonism in late stages Methanol Tx - Precise Answer ✔✔ • EtOH has greater affinity for EtOH dehydrogenase and saturates it, preventing breakdown of methanol into its toxic metabolites
- Fomepizole has even greater affinity and less S/Es than EtOH
- NaHCO3 used for acidemia
- Consider folate supplementation Methanol - Precise Answer ✔✔ Metabolism to formic acid and elimination of folate stores leads to toxicity. Metabolism occurs by EtOH dehydrogenase in the liver Salicylates - Precise Answer ✔✔ • Early: Resp alkalosis due to stimulation of CNS chemoreceptors
- Late: metabolic acidosis
- Severe toxic dose >300 mg/kg, toxic dose considered to be >150 mg/kg Salicylates - Precise Answer ✔✔ • Symptom onset 3-8 h after ingestion
- Dehydration common
- Adults: mixed acid-base with Resp alkalosis and metabolic acidosis
- Children: metabolic acidosis only; indistinguishable from Reye syndrome
- Salicylate levels helpful to determine severity Salicylates - Precise Answer ✔✔ • Whole Bowel Irrigation or Activated Charcoal for large ingestions; Activated Charcoal may be helpful >2 h after (''It's never to late to aspirate with salicylate'')
- ++ Fluids +/− dextrose +/− K
- NaHCO3 to ↓ tissue distribution and ↑ urine elimination Acetaminophen - Precise Answer ✔✔ • Metabolized almost exclusively in the liver; 5% forms toxic metabolite
- Toxic metabolite is conjugated by glutathione and excreted; in OD glutathione stores are depleted and hepatocytes are susceptible to the effects of the toxic metabolite, leading to a picture of hepatotoxicity
- Toxic dose reported as 150 mg/kg or >7.5 g ingested Acetaminophen
- Initial Sx of anorexia, nausea+/−vomiting, and diaphoresis subside in 24-48h; patient may then become asymptomatic - Precise Answer ✔✔ • This is the ''calm before the storm'' and patients may later present as hepatic failure if ingestion is severe enough
- Toxicity determined by Rumack-Matthew nomogram; must draw acetaminophen levels at 4 h postingestion
and to determine probable or possible hepatic toxicity Acetaminophen Tx - Precise Answer ✔✔ • N-AcetylCysteine is specific antidote and is 100% effective in preventing toxicity if given within 8 h of severe ingestion
- Liver transplantation may be only choice if hepatic failure imminent Active external rewarming technigues - Precise Answer ✔✔ • Bath immersion at 40◦C
- Hot water bottles
- Heating pads
- Forced-air warming systems (Bair Hugger) Active internal (core) rewarming techniques - Precise Answer ✔✔ • Warmed crystalloids
- Heated, humidified O2 at 41◦C
- Peritoneal Dialysis
- Heated irrigation (gastric, thoracic, pericardial)
- Diathermy (with ultrasonic or microwaves)
- Extracorporeal (venovenous, HD, continuous AV, and CPB)
Ideal cooling techniques
- Evaporative cooling or body cooling unit
- Ice water immersion - Precise Answer ✔✔ • Ice water immersion particularly effective in hypotensive patient → promotes vasoconstriction
- Specialized equipment needed (fans, water at 40◦C, etc.)
- Ice water immersion may complicate resuscitation efforts Hypothermia LABWORK/INVESTIGATIONS - Precise Answer ✔✔ CBC, Lytes, gluc., INR/PTT, ABG, amylase, ECG, CXR TCAs
- Tertiary amines block norepinephrine and serotonin reuptake, and their metabolites, 2◦ amines predominantly affect norepinephrine reuptake - Precise Answer ✔✔ • Also have anticholinergic and antihistaminic effects TCAs Tox
- Symptom onset within 6 h
- Dx made on clinical grounds; no specific levels - Precise Answer ✔✔ • May see dizziness, confusion, agitation, and variable anticholinergic effects; presentation is often nonspecific
- ECG findings characteristic: may see prolonged QRS, PR, or QT +/− right axis deviation of terminal 40 mV of QRS (seen as R wave in lead aVR and S wave in lead I) TCAs Tox
- Rx is supportive
- Activated Charchoal if ingestion <2 h - Precise Answer ✔✔ • Benzodiazepines for seizures
- NaHCO3 for ECG changes
- ++Fluids+/−pressors for hypotension Heat Exhaustion - Precise Answer ✔✔ • Temperature 37.5◦C- 40.5◦C
- Mental function intact
- Malaise, fatigue, headache
- ↑ HR, + orthostatics, clinical dehydration Heat Stroke
- Temperature classically >40.5◦C
- CNS dysfunction (coma, seizures, death)
- Liver transaminases ↑ - Precise Answer ✔✔ • ''Classical'' heatstroke occurs usually in an elderly patient due to ↓heat dissipation
- ''Exertional'' heatstroke tends to occur in younger individuals due to exercise in high ambient temperatures
+/− high humidity Top Causes of Trauma Fatalities in Canada - Precise Answer ✔✔ 1. Motor Vehicle Collision
- Falls
- Firearms Hemorrhagic/hypovolemic shock CO↑ (↑ HR, ↑ contractility) SVR↑ (Peripheral vasoconstriction) BP Narrowed pulse pressure - Precise Answer ✔✔ BP and HR are poor indicators of hemorrhagic and distributive shock as they depend on the patient's underlying health and physiologic reserve. CO will initially ↑ but, as hemorrhage continues, the patient will eventually decompensate leading to ↓ CO and BP. Distributive shock e.g., septic, anaphylactic) - Precise Answer ✔✔ CO ↓ (↓ Preload) SVR ↓ (Peripheral vasodilation) BP Widened pulse pressure Cardiogenic shock - Precise Answer ✔✔ CO ↓ (↓ Contractility) SVR ↑ or Normal BP ↓
Obstructive shock e.g., tamponade, PE, tension pneumothorax) - Precise Answer ✔✔ CO↓ SVR↑(Primarily due to venocongestion) BP ↓ The skin is made up of four layers: - Precise Answer ✔✔ epidermis, dermis, superficial fascia, and deep fascia ''SAMPLE'' Hx: - Precise Answer ✔✔ S—Signs and symptoms of injury/illness A—Allergies M—Medications P—Past Medical History, pregnancy L—Last oral intake, including EtOH/drugs (present in 30% of cases) E—Events surrounding the accident/trauma Critical Adjuncts to Primary Survey - Precise Answer ✔✔ • Regular vitals
- Pulse oximetry
- ECG + telemetry
- I V fluids-2 L of RL
- Urinary catheter
- Gastric catheter
- Temperature control Trauma Lab Panel
- CBC
- blood Group & Screen or cross-match
- INR, PTT
- Lytes
- BUN, Cr
- β-HCG in female - Precise Answer ✔✔ Consider:
- ABG
- Lipase, amylase
- LFTs
- Drug panel trauma Diagnostic Studies - Precise Answer ✔✔ • AP CXR
- AP pelvis
- C-spine series
- Diagnostic Peritoneal Lavage or FAST
- Additional XR of suspected injuries
- CT head/Abdo as appropriate
POTENTIAL COMPLICATIONS OF TRAUMA TX AND
RESUSCITATION
- Decubitus ulcers
- DVT and PE — Prophylaxis consists of daily subcutaneous enoxaparin or LMWH.
- Transfusion complications - Precise Answer ✔✔ Transfusion complications: infection (HBV, bacterial pathogens); immunologic (↓ cell mediated immunity, proinflammatory effects); metabolic (hypothermia, acidosis, coagulopathy, hyperkalemia, hypocalcemia, and citrate toxicity); mistransfusion (ABO incompatibility). FAST Assesses for free fluid in four areas - Precise Answer ✔✔ the four ''Ps'': Perisplenic, Perihepatic, Pelvic, and Pericardial INDICATIONS FOR EMERGENT SURGICAL CONSULTATION AND LAPAROTOMY
- Hemodynamically unstable patient with abdominal, back or flank trauma
- Obvious GI evisceration
- P/E findings consistent with peritonitis - Precise Answer ✔✔ • Transabdominal gunshot wound
- Penetrating wound that extends through the fascia ± a positive DPL
- Free air present on either plain XR or CT
- Abdominal organ injury as seen on CT that requires surgical repair Causes of Hypotension in the Abdominal Trauma Patient - Precise Answer ✔✔ • Acute blood loss/hemorrhagic shock
- Spinal shock
- Toxic ingestion
- Pregnancy
- Acute and chronic Resp or cardiac disease Beck's Triad: Cardiac Tamponade - Precise Answer ✔✔ 1. Elevated JVP
- ↓ BP
- Muffled heart sounds CXR Signs of Aortic Disruption
- Widened mediastinum (>8 cm) - Precise Answer ✔✔ • Indistinct aortic knob
- Depressed left main bronchus
- Tracheal deviation (right)
- NG tube deviation
- Widened right paratracheal stripe (>5 mm)
- Apical capping
- Loss of space between the pulmonary artery and aorta Indications for Immediate ED Thoracotomy - Precise Answer ✔✔ • Acute hemodynamic instability or cardiac arrest in the ED and
- Penetrating thoracic injury ± signs of electrical cardiac activity
- Blunt thoracic injury + electrical cardiac activity
- Great vessel injury
- Cardiac tamponade
- Suspected air embolus
- Known esophageal, tracheal, or bronchial injury Presentation of Acute Aortic Rupture - Precise Answer ✔✔ • Chest or midscapular pain
- Dyspnea
- Hoarseness
- Dysphagia May be asymptomatic Classification of Head Injury - Precise Answer ✔✔ • Mild: GCS 13 to 15
- Moderate: GCS 9 to 12
- Severe: GCS <9
Presentation of ↑ ICP - Precise Answer ✔✔ • Headache
- Nausea, vomiting
- ↓ Level of consciousness
- Papilledema Canadian CT Head Rules CT of any patient with a mild TBI (GCS = 13 to 15) plus:
- High risk factors
- GCS <15 2 h after injury
- Suspected open or depressed skull fracture
- Any sign of basilar skull fracture - Precise Answer ✔✔ • Two or more episodes of vomiting
- Older than 65 yr
- Medium risk factors
- Amnesia before impact of ≥30 min
- Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from vehicle, fall from ≥3 ft or ≥5 stairs) Shaken Baby Syndrome - Precise Answer ✔✔ Owing to the violent shaking of infant's body or head→ acceleration-deceleration injury
and cervical whiplash Suspect with subdural hematomas
- retinal hemorrhages Signs of Basilar Skull Fracture - Precise Answer ✔✔ • Battle's sign: postauricular ecchymosis
- Raccoon eyes
- CSF rhinorrhea or otorrhea
- Hemotympanum or laceration of the external auditory canal IntraVentricular Hemorrhage - Precise Answer ✔✔ Caused by shearing of vessels within the brain parenchyma Lateral ventricles and third ventricle CT: Focal areas of blood within the ventricles SubArachnoid Hemorrhage - Precise Answer ✔✔ May be 2◦ to trauma or due to rupture of an aneurysm Blood collects in the space between the arachnoid and the pia CT: Area of high density that is spread thinly over the convexity of the brain Epidual Hematoma - Precise Answer ✔✔ Due to meningeal artery injury, typically the middle meningeal artery
Blood collects between the skull and the dura mater CT: Usually biconvex (the ''lens'' sign) Intracerebral Contusion and Hemorrhage - Precise Answer ✔✔ Caused by shearing of vessels within the brain parenchyma Most commonly located in the frontal and temporal lobes CT: Diffuse area of high density in the brain parenchyma, adjacent to the bony prominences Acute Subdural Hematoma - Precise Answer ✔✔ Injury of the bridging veins running from the surface of the brain to the superior sagittal sinus Blood collects between the dura and arachnoid layers CT: Usually crescent shaped. Acute = high density Cerebral Edema - Precise Answer ✔✔ Vasogenic, cytotoxic, or hydrocephalic in nature May be localized to area of injury or may be diffuse CT: Shift of midline structures, particularly if focal edema Diffuse Axonal Injury - Precise Answer ✔✔ Shearing of axons due to deceleration or rotational forces about the brain In the deep white matter and midbrain
CT may initially be normal. Evolves to show loss of gray-white interface and/or multiple small hemorrhages Diagnostic Tests in Determining Brain Death - Precise Answer ✔✔ • Apnea test
- Assess brainstem reflexes
- Ancillary tests—four-vessel cerebral angiogram or radionucleotide CBF imaging can be done for confirmation Diagnostic Tests in Determining Brain Death
- Apnea test - Precise Answer ✔✔ preoxygenate the patient; discontinue mechanical ventilation but deliver 100% O2 through ETT. Observe for ventilatory effort. Test is complete when: ABGs show pH ≤ 7.28, PaCO2 ≥60 mm Hg, and a PaCO2 ≥20 mm Hg from baseline
- Assess brainstem reflexes - Precise Answer ✔✔ gag and cough, pupillary constriction, corneal reflex, and vestibulo-ocular reflex should all be absent Determination of Brain Death - Precise Answer ✔✔ To be able to declare a patient neurologically dead, one must be an independently practicing physician with skill and experience in severe brain injury and neurologic death