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SAEM - Procedures
The joint fluid from a patient's knee arthrocentesis shows 75,000 WBC with 75% PMNs, no organisms, no crystals and a glucose of 35. What does the patient need next? A. antibiotics for septic joint and admission for operation B. antibiotics and discharge home C. narcotic pain medicine and discharge home D. non-steroidal anti-inflammatory medicine for gout and discharge home E. treatment for gonorrhea and discharge home - correct answer The correct answer is A. The key to successful treatment of a septic joint is rapid diagnosis and treatment. Hospital admission for wash out of the joint and IV antibiotics are indicated for a septic joint. Antibiotics should be started based on gram stain or consideration of likely organisms and then adjusted based on final culture results. A patient presents after slamming her index finger in a window one day ago (see Figure). Her X-ray is negative. Of the steps listed below, which is the best option for her management? [image] A. antibiotics and discharge B. drainage and discharge C. removal of the nail and suture of the underlying laceration D. splint and discharge E. none of the above - correct answer The correct answer is B. This patient has a subungual hematoma. Large subungual hematomas require drainage using an 18- gauge needle or a hot microcautery unit. There is debate concerning management of a subungual hematoma greater than 50% of the nail bed. One study showed there was a 60% incidence of nail bed laceration in these patients; therefore, the authors recommended that the nail be removed and the laceration sutured. However, another study found no difference in outcome between nail trephination alone versus formal nail bed repair.
You have a 3 year old female present with her mother with complaints of 2 days of left ear pain. On exam, you are unable to visualize the tympanic membrane due to an obstructing mass. You suspect a foreign body. Which of the following is TRUE regarding the removing a foreign object from the patient's ear canal? A. To remove a live insect from the external ear canal, grasp a leg with hemostats and pull firmly B. You should avoid the use of lidocaine and other topical anesthetics due to the risk of localized tissue ischemia C. Avoid suction as it may lead to a perforation of the tympanic membrane D. Referral to an otolaryngologist for foreign body removal under general anesthesia may be required in an uncooperative infant - correct answer The answer is D. Irrigating the ear canal with warm water is acceptable in many instances, and may remove a foreign object with minimal discomfort. Direct the water jet gently past the object, against the tympanic membrane, and then back out the ear canal, hopefully dislodging the foreign object in the process. However, this technique should not be used in cases of bean or seed insertion because such objects swell when moistened, which makes subsequent removal more difficult and increases the risk of pressure necrosis. Irrigation should also be avoided in cases of tympanic membrane perforation. You suspect that your patient has swallowed a nail. Which of the following is an indication for endoscopic or surgical removal of this object? A. Radiography visualizes the nail in the gastric fundus B. The object has progressed from the jejunum through the ileum after 24 hours C. Abdominal CT scan shows a 1cm nail in the distal sigmoid colon D. Plain films do not reveal a radiopaque foreign body in the chest or abdomen - correct answer The answer is A. Observation can manage most ingested foreign objects - the patient should pass the object after several days. Propulsive agents can be given to speed movement along the gastrointestinal tract. Serial radiography monitors movement. Endoscopic or surgical intervention is indicated for sharp objects (which may cause perforation), objects greater than 2 cm in width (which are likely to lodge at the pylorus or the ileocecal valve), and long rigid objects (which may have trouble passing through the right angles of the duodenum). Surgery is indicated if an object fails to move after 24 hours (indicating impaction), or if the patient develops symptoms of obstruction or perforation. Body packers may have ingested substances such as cocaine or heroin, which can cause great harm should the packaging be disrupted. Proper management is
E. Use of a "finder needle" to mark suture entry points. - correct answer The answer is C. Eversion of the skin edges is maximized by directing the needle entry as shown in the figure. Injection for local anesthesia should usually be performed through the wound, rather than through intact skin. Use of skin clamps can damage tissue; in cases where skin stabilization is needed gentle forceps application is preferred. Subcuticular sutures are placed deep to the skin. The components of the Figure (which is a photograph taken of the female perineal region) depict __________ (in the top of the Figure) which can be treated by placement of a __________ (in the lower part of the Figure): [image] A. an inguinal lymph node -- gel-applicator for antibiotics administration B. a benign tumor -- brachytherapy applicator C. a cystocele -- pessary D. a Bartholin's cyst -- Word catheter E. a urinoma -- pediatric Foley catheter - correct answer The answer is D. The patient's Bartholin's cyst will be drained, and placement of a Word catheter (inserted through an incision on the mucosal surface of the labia) will allow for continued drainage and healing. With respect to larygneal assessment, the Figure depicts what grading scale? [image] A. Cormack-Lehane B. LMA C. Macintosh D. Mallampati E. Miller - correct answer The answer is A. The Cormack-Lehane scale allows communication of relative ease of visualization of laryngeal structures during laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway. A 7 year old girl with severe asthma presents to the emergency department in severe respiratory distress. She clearly has difficulty breathing on her own and is
obviously "tiring out." Her oxygen saturation is 85% and falling. The decision is made to intubate her. Of the following agents, which is often recommended (due to its bronchodilatory effects) as the induction agent of choice? A. Pentobarbital B. Midazolam C. Ketamine D. Etomidate - correct answer The answer is C. Ketamine is a dissociative anesthetic and relaxes bronchial smooth muscle, either by blocking parasympathetic effects or by increasing sympathomimetic stimulation. This relaxation can decrease airway resistance within minutes of administration. While the clinical relevance of ketamine's bronchodilation is subject to debate, most major texts mention it as an agent of choice for intubation of patients with reactive airways disease. All of the other induction agents mentioned do not cause bronchodilation. A 67-year old male presents in acute respiratory failure. You have chosen etomidate as the induction agent to perform rapid sequence intubation (RSI) on your patient. He is allergic to eggs and penicillin. Which of the following is true regarding etomidate? A. Has a large side effect profile and other agents should be considered first for induction in RSI B. Is not safe to use in patients with cardiovascular disease due to its detrimental effects on myocardial contractility C. It should not be used in patients allergic to soy or eggs D. May cause transient adrenal suppression and should be used with caution in septic patients - correct answer The answer is D. Etomidate has an acceptable side effect profile and is one of the primary induction agents in RSI. It is a sedative, reduces anxiety and is cardio-protective. Therefore it is primarily indicated for induction when decreased myocardial contractility is a concern. Patients allergic to soy or eggs should not receive propofol, but etomidate is safe to administer. Etomidate has been known to cause transient adrenal suppression and its use in septic patients is controversial. A 45 year-old construction worker has sustained a 4 cm, superficial laceration over his dorsal, left forearm by a segment of broken glass. Which of the following local anesthetics is characterized by average potency (lipid solubility), low toxicity and rapid onset of action?
C. The patient is undergoing infusion of anesthesia into the saphenous vein. D. The patient shown is undergoing a sural nerve block. E. The patient shown is undergoing a posterior tibial nerve block. - correct answer The answer is E. The nerve block depicted is a posterior tibial block. Regional blocks are preferred for procedures involving the plantar foot, since there is rich innervation and significant discomfort associated with injections into the soles. The posterior tibial nerve, located between the medial malleolus and Achilles tendon, supplies the medial portion of the sole and the medial side of the foot. The nerve runs next to the posterior tibial artery and is posterior to the pulse. In addition to the posterior tibial nerve block, a sural nerve block is frequently provided when anesthesia is desired for the heel and lateral foot. Which of the following is an absolute contraindication to surgical cricothyrotomy? A. Acute laryngeal disease B. Bleeding diathesis C. Age < 5 D. Massive neck edema - correct answer The answer is C. Given that surgical cricothyrotomy is often resorted to only after other techniques have been unsuccessful and/or the patient is not oxygenating or ventilating, most authors state that the only absolute contraindication is age. Because of the anatomic differences between children versus adults including the smaller cricothyroid membrane and the rostral funnel shaped more compliant pediatric larynx, surgical cricothyrotomy has been contraindicated in infants and young children. However, the exact age at which a surgical cricothyrotomy can be done is controversial and not well defined. Various textbooks list the lower age limit from 5 years to 12 years. Choices A, C, and D are all relative contraindications to cricothyrotomy but may be overlooked in an emergent situation when the first priority is to obtain an airway. A 56 year old energy plant worker with a history of coronary heart disease and mild asthma severs a sharp, metal wire that snaps back and cuts his finger. He does not report a great deal of bleeding, but a 3-cm laceration on the distal right index finger requires sutures for repair. Of the approaches below, which is the best choice for pre-suturing anesthesia? A. lidocaine-epinephrine injection (lidocaine 2.0%, epinephrine 1:1000) as a digital nerve block anesthesia
B. lidocaine-epinephrine injection (lidocaine 2.0%, epinephrine 1:1000) as a local infiltration anesthetic C. lidocaine-epinephrine topical solution (lidocaine 2.0%, epinephrine 1:1000) D. lidocaine injection (lidocaine 2%) as digital nerve block anesthetic - correct answer The answer is D. In some cases surgical or dermatological consultants may utilize epinephrine-containing anesthetics in tissues with end-arterial blood supply. Although epinephrine-containing solutions are used routinely by podiatrists in digital blocks of the toes, without morbidity, when performing a digital block, it is advised to use anesthetics that do not contain epinephrine. If epinephrine-containing solutions are inadvertently used for a digital block in otherwise healthy individuals without peripheral vascular disease, it is unlikely that serious ischemic injury will occur. In the emergency department you should follow the general rule proscribing use of such agents in the digits, tip of the nose, penis, and pinna. The rationale for this prohibition is that vasoconstriction in these regions can result in ischemic complications, especially if the patient has underlying peripheral vascular disease. This patient was at risk. Standard concentrations of lidocaine are not likely to achieve effective analgesia when used topically. Regarding the eyebrow laceration, in a 30-year old female, as depicted in the Figure, which of the following is true? [image] A. If there is not much tension on the wound, a topical adhesive (such as Dermabond) may be used to approximate the wound edges B. The eyebrow hair should be shaved to optimize the ability to closely approximate the wound edges C. This laceration is not suitable for topical anesthesia as an adjunct to repair D. An infraorbital nerve block would provide adequate anesthesia to the area of the laceration E. If lidocaine anesthesia is to be used, the solution should not contain epinephrine
- correct answer The answer is A. Eyebrow hair tends to not regrow after being shaved; a petroleum jelly can be used to "retract" the hair if necessary. If anesthesia is to be used to close this wound (wound glue would be a reasonable alternative), topical anesthesia is a good approach as long as care is taken to prevent drip into the eye. An infraorbital nerve block would not provide anesthesia to the area of the laceration. Epinephrine can be used safely in the supraorbital region. A patient sustains a forearm laceration as shown in the Figure. Regarding the wound, which of the following is true?
A. Randomized clinical trials have established the importance of prophylactic antibiotics in patients such as this one. B. An ulnar nerve block would be a preferred method for wound anesthesia. C. Vertical mattress sutures should be used for wound closure. D. The wound should be closed with a topical skin adhesive such as 2-octyl cyanoacrylate. E. Since it is difficult to sufficiently irrigate the palm, the laceration should be left open. - correct answer The answer is B. An ulnar nerve block provides anesthesia and is likely less painful than direct injection into the wound (which is another reasonable approach to wound anesthesia). Vertical mattress sutures are not recommended for the palm, as this technique places deep structures at risk. Topical skin adhesives are best avoided in the palm, which is prone to sweating and thus increasing the possibility of resultant wound dehiscence. Though many would recommend use of prophylactic antibiotics in a patient with a sufficiently deep palmar laceration, no controlled trials address use of antibiotics in patients with this
- or just about any other - type of laceration. You are performing procedural sedation to repair a complex facial laceration on a child in the ED. Unfortunately your patient is progressing from clinical signs of moderate sedation to deep sedation and is in need of reversal using flumazenil. In which of the following scenarios is the use of flumazenil appropriate? A. Patient is younger than 3 years old and had a glass of milk four hours ago B. Patient has been given IV ketamine as a single agent for sedation C. Patient exhibits signs of seizure activity during procedural sedation D. Patient has been given IV fentanyl as a single agent for sedation - correct answer The answer is A. Flumazenil should not be used on a patient exhibiting seizure activity (A). Also co-ingestion of drugs with pro-convulsant properties (cyclic antidepressants) is associated with an increased risk of seizures, presumably due to loss of the benzodiazepine's protective anticonvulsant effect when the antagonist is administered. For similar reasons (related to GABA effects) flumazenil can theoretically precipitate seizure activity in patients who chronically take benzodiazepines or chloral hydrate. The co-administration of flumazenil also risks cardiac side effects for these patients. Flumazenil would not be indicated for reversal of sedation when using only fentanyl or ketamine (B, D). Naloxone (or another opioid antagonist), not flumazenil, is the appropriate reversal agent for fentanyl. There is no reversal agent available for ketamine. Flumazenil can be used for the acute reversal of benzodiazapine overdose in procedural sedation for
children younger than 3. The patient's consumption of milk four hours earlier met the ASA fasting guidelines and is irrelevant. You are performing procedural sedation on a 42 year old male who is quite muscular and requires high doses of analgesia to reduce a dislocated hip sustained during an MVA. He begins to show signs of respiratory depression and needs manual ventilation with a bag valve mask. You are having great difficulty providing manual ventilations due to presumed spasm of the glottis and rigidity of the chest wall musculature. Which of the following analgesics was likely used? A. Fentanyl B. Morphine C. Demerol D. Dilaudid - correct answer The answer is A. This patient is exhibiting clinical signs of chest wall rigidity and glottic spasm, which is a rare but classic side effect of using high doses of intravenous fentanyl. Chest wall rigidity and glottic spasm, which may make ventilation difficult, are unique complications seen with very high doses of fentanyl given rapidly (generally > 15 mcg/kg). It has been observed at lower doses. This may not reliably be antagonized by naloxone and may require neuromuscular blockade and intubation to enable adequate ventilation. This complication is very rarely reported with the dosages of fentanyl used for PSA but can still happen. With respect to airway assessment, the Figure depicts what classification scale? [image] A. Macintosh B. Cormack-Lehane C. Miller D. LMA E. Mallampati - correct answer The answer is E. The Mallampati scale allows communication of ability to visualize structures of the posterior oropharynx, as a means of predicting ease of laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway.
A 21-year old male presents with a clean-knife wound sustained 24 hours ago. The laceration is 2cm in length, and located between the MCP and PIP levels of the nondominant hand index finger, on the flexor surface; the wound is well- approximated (i.e., not gaping). The patient has not had tetanus immunization within 10 years and has no complaints other than pain at the laceration site. Which of the following regarding this patient/presentation is TRUE? A. The wound should be sutured, primarily to minimize the chances of infection. B. The wound should be sutured, primarily due to the potential for dehiscence due to tension on the skin edges. C. Simple wound cleaning, bandaging, and tetanus immunization are appropriate therapy for this patient. D. It is too late (at 18 hours post-injury) to provide tetanus immunization. E. Since the wound appears superficial, there is no risk of involvement of the neurovascular bundle. - correct answer The answer is C. Tetanus can be probably be effective if administered within the first few days of a wound; 24 hours is not too late. Suturing of this wound is not indicated, since it is an old wound, well- approximated, and is on the flexor surface of the digit where skin forces will be minimal. Though suturing is not indicated, careful assessment of the finger for neurovascular injury is appropriate given the anatomical location of the wound over the bundle (the superficial appearance of the wound may be misleading). A 25 year old male college student with a history of type I diabetes mellitus presents to the emergency department complaining of worsening headache, vomiting, and fever. On exam, he has a temperature of 101.6 F, meningismus, and photophobia. A lumbar puncture is performed and reveals a CSF glucose consistent with bacterial meningitis. What is the normal ratio between CSF and serum glucose? A. 1: B. 2: C. 0.4: D. 0.6:1 - correct answer The answer is D. The normal range of CSF glucose is 50 to 80 mg/dL, which is 60% to 70% of the glucose concentration in the blood. Ventricular fluid glucose levels are 6 to 8 mg/dL higher than in lumbar fluid. A ratio of CSF glucose-to-blood glucose of less than 0.5 or a CSF glucose level below 40 mg/dL is invariably abnormal. The ratio is higher in infants, for whom a ratio of less than 0.6 is considered abnormal. Hyperglycemia may mask a depressed CSF glucose level; when present, the CSF glucose-to-blood glucose ratio should be
measured routinely. With extreme hyperglycemia, a ratio of 0.3 is abnormal. In patients with systemic hyperglycemia, the ratio changes to 0.4:1. An 18 year old male is transported to the emergency department after being involved in a motor vehicle collision. On initial evaluation, he is found to be comatose, hypotensive, and is diagnosed clinically as having a tension pneumothorax on the left side. What is the correct statement regarding needle decompression or chest tube placement in this patient? A. Placement of the needle should be in the 3rd ICS, midaxillary line. B. The chest tube should be inserted under the lower edge of the rib C. A chest x-ray is unnecessary before needle decompression D. An 18 French chest tube would be appropriate in this situation. - correct answer The answer is C. In an unstable patient such as this, a chest x-ray would delay the care of this patient and is unnecessary. This patient needs immediate intervention with needle decompression. A chest tube size of #28 French or greater would be indicated since this patient may have a hemothorax (B). Needle decompression involves placement of a #14 gauge needle in the 2nd intercostal space at the midclavicular line (C). The chest tube should be inserted over the upper border of the rib to avoid the neurovascular bundle at the inferior margin of each rib. The Figure depicts a patient with toe pain. She does not recollect any trauma. Regarding the Figure and her presentation, which of the following is true? [image] A. The cellulitis in the toe is the primary problem B. The indicated procedure will likely be able to be performed without anesthesia in this patient C. Occult trauma and fracture are the most likely diagnoses, and the patient will probably require splinting after X-ray D. This patient can be managed with a simple surgical procedure, with no need for outpatient medications other than analgesics E. Digital block, a surgical intervention, and antibiotic therapy are all indicated in this patient - correct answer The answer is E. This patient has a paronychia, complicated by relatively significant extension of purulence as well as cellulitis in the involved great toe. In cases where the paronychia is small, simple lifting of the eponychium (cuticle) may suffice; no digital block is necessary. In a case such as
