Sleepy Joe
While performing a laceration repair on a healthy 20-year-old man, a large volume of bupivacaine solution is inadvertently injected intravascularly. Shortly after, the patient develops mouth tingling and a metallic taste before becoming bradycardic, hypotensive, unresponsive, and finally pulseless. After securing the patient’s airway and initiating CPR, which of the following is the best next step in definitive management?
A. Atropine IV
B. Calcium IV
C. HD
D. Lipid emulsion IV
D. Lipid emulsion IV
Which of the following is the most appropriate treatment for cyanide toxicity?
A. Amyl nitrite and sodium thiosulfate
B. HD
C. Hydroxycobalamin
D. Hyperbaric oxygen
A 19-year-old man with depression presents after an intentional overdose of his citalopram 4 hours prior to arrival. His vital signs and ECG are unremarkable. Which of the following is the most appropriate next step in management?
A. Admit to psychiatry
B. Give cyproheptadine
C. Observe on telemetry monitoring
D. Start HD
C. Observe on telemetry monitoring
A 55-year-old man with a history of hypertension presents to the emergency department with altered mental status. His spouse reports finding him confused and lethargic at home. The patient reports no recent illnesses but reports accidentally taking extra doses of his prescribed beta-blocker medication. What is the most common complication related to this ingestion?
A. Bradycardia
B. Bronchospasm
C. Hypoglycemia
D. Seizure
A. Bradycardia
Hannah is a 19-year-old farmer presents to the ED with vomiting, diarrhea, diaphoresis, wheezing, and excessive tearing. Vital signs are BP 170/100 mm Hg, HR 36 bpm, RR 28/min, and T 98.6°F (37ºC). Which of the following is the most appropriate initial step in care?
A. Atropine
B. Decontamination
C. Endotracheal Intubation
D. High dose insulin
B. Decontamination
A 40-year-old man with chronic back pain presents to the ED with altered mental status. His spouse notes he has been reporting ringing in his ears. On physical exam, you find that the patient is diaphoretic, warm to the touch, and is oriented only to person. Vital signs are BP 110/75 mm Hg, HR 120 bpm, RR 28/minute, and T 100.4°F (38°C). Which of the following is the most appropriate next step in management?
A. Deferoxamine
B. NAC
C. Pralidoxime
D. Sodium bicarbonate
D. Sodium bicarbonate--salicylate tox!
A 16-year-old boy swallows a large volume of drain cleaner in a suicide attempt. Which of the following is most likely to be associated with this ingestion?
A. Coagulative necrosis of the stomach
B. Hypocalcemia and hypomagnesemia
C. Liquefaction necrosis of the esophagus
D. No significant injury
C. Liquefaction necrosis of the esophagus
Patient is a 21 year old woman with a history of depression and anxiety presents to the ED with a fever and diaphoresis. She reports no cough, dysuria, abdominal pain, rash, or recent travel. She is adherent to her medications and began taking a new one today. She appears restless and agitated. Her vital signs are T 102°F (38.9ºC), HR 124 bpm, RR 16/minute, BP 150/95 mm Hg, and SpO2 100% on room air. Her blood glucose is 112 mg/dL, and her urine pregnancy test is negative. Which of the following findings suggests the diagnosis of serotonin syndrome?
A. Bilateral miosis
B. Cogwheel rigidity
C. Lower extremity clonus
D. Torsional nystagmus
C. Lower extremity clonus
A 63-year-old man with a history of atrial fibrillation presents after a syncopal episode. His ECG shows a downsloping ST segment. Which medication is the patient likely to be taking?
A. Amiodarone
B. Carvedilol
C. Digoxin
D. Flecanide
C. Digoxin
A 27-year-old man presents to the emergency department acutely confused. His T is 97°F (36.1°C), BP is 105/60 mm Hg, HR is 52 bpm, RR is 25/min, and SpO2 is 95% on room air. Physical exam reveals profuse tearing of the eyes and drooling. The patient has wheezing on the pulmonary exam. His pupils are 1 mm and reactive. He is covered in sweat, and his skin is cool. Which of the following treatments is the best for this patient right now?
A. Atropine
B. Cyproheptadine
C. Diazepam
D. Physostigmine
A. Atropine
A 17-year-old girl with bipolar disorder presents to the ED after a suicide attempt. She has vomited twice and is reporting abdominal pain. Her serum acetaminophen level is 170 mcg/mL. N-acetylcysteine is given. What is the mechanism of action of N-acetylcysteine?
A. Delays hepatocyte apoptosis
B. Inhibits glutathione
C. Regenerates N-acetyl-p-benzoquinoneimine
D. Regenerates sulfhydryl donor
D. Regenerates sulfhydryl donor
Lizzie Barrett presents to the emergency department after eating several death cap mushrooms. He is having abdominal pain, nausea, vomiting, and diarrhea. Which of the following treatments might be indicated to treat the major complication associated with this ingestion?
A. Atropine
B. Diazepam
C. NAC
D. Physostigmine
C. NAC
There is no clear or life-saving antidote for this ingestion other than supportive care. Treatment may include early administration of charcoal and gastric lavage (ideally within 1 hour of ingestion), diuresis, plasmapheresis, benzylpenicillin, N-acetylcysteine, silymarin, vitamin C, cimetidine, and liver transplantation if there is liver failure.
Christine Wolf presents with hyperthermia, hypertension, and altered mental status. He was recently started on haloperidol for schizophrenia. Physical examination reveals a confused patient with muscle rigidity. Which of the following medications should be administered?
A. Benztropine
B. Cyproheptidine
C. Lorazepam
D. Naloxone
C. Lorazepam
A 25-year-old man presents to the emergency department after a suicide attempt in which he overdosed on his parent’s medications. He is unable to offer a history upon arrival. His T is 96°F (35.6°C), BP is 75/50 mm Hg, HR is 42 bpm, RR is 12/min, and SpO2 is 93% on room air. Fingerstick blood glucose is 40 mg/dL. Which of the following is the most likely cause of this patient’s symptoms?
A. Digoxin
B. Glyburide
C. Insulin
D. Propanolol
D. Propanolol
A large number of patients are presenting to the ED with varying degrees of ocular and blistering dermal burns after a chemical warfare attack in the city. Those closest to the point of attack have arrived intubated with blood-filled endotracheal tubes. Which chemical warfare agent was most likely used in this attack?
A. Cyanide
B. Mustard
C. Phosgene
D. Sarin
B. Mustard
What is the minimum dose of ibuprofen considered necessary to cause symptomatic toxicity when taken in overdose?
A. 100 mg/kg
B. 150 mg/kg
C. 50 mg/kg
D. 75 mg/kg
A. 100 mg/kg
A 6-year-old girl without any significant medical history presents to the emergency department with her parents after she spilled gasoline on herself while alone in their garage. The parents found her coughing and immediately cleaned the gasoline off of her. The girl thinks she swallowed some but reports no vomiting or gagging. Her vital signs include temperature 37.2°C, heart rate 98 bpm, blood pressure 110/60 mm Hg, respiratory rate 22/min, and oxygen saturation 98% on room air. Her lungs are clear to auscultation bilaterally and she is breathing comfortably without retractions. The rest of her exam is normal. What is the most appropriate next step in care?
A. Abdominal X-ray and discharge if normal
B. Chest X-ray and observe for 4 hours
C. Immediate gastric decontamination
D. Observe for 6 hours post-ingestion and then perform a chest X-ray
D. Observe for 6 hours post-ingestion and then perform a chest X-ray
Management of hydrocarbon exposures for asymptomatic patients requires observation for 6 hours post-ingestion and X-ray at that point or earlier if the patient becomes symptomatic.
A 22-year-old woman presents to the emergency department after an intentional overdose. She has a history of depression and bipolar disorder. The patient was found altered and minimally responsive by her parent with a suicide note. On arrival, the patient is altered and making nonsensical speech. Vital signs are remarkable for an HR of 120 bpm, RR of 28/min, and BP of 180/95 mm Hg. Which physical exam feature is most supportive of a tricyclic antidepressant overdose?
A. clonus
B. diaphoresis
C. dry mucous membranes
D. frequency
C. dry mucous membranes
A 64-year-old man presents to the ED with palpitations, diplopia, photophobia, nausea, vomiting, and diarrhea. He has a history of atrial fibrillation, ischemic cardiomyopathy, hypertension, and diabetes mellitus. His home medications include metoprolol, aspirin, atorvastatin, digoxin, lisinopril, and metformin. What ECG findings would be most suggestive of digoxin toxicity in this patient?
A. Bidirectional ventricular tachycardia
B. Diffuse QRS complex widening with a terminal R wave in lead aVR
C. Downsloping ST depression with a terminal positive deflection and biphasic T waves
D. Prominent S wave in lead I, with a prominent Q wave and T wave inversion in lead III
E. Small positive deflection buried in the end of the QRS complex in leads V1–V4
A. Bidirectional ventricular tachycardia
A 34-year-old man presents to the ED with vomiting after exposure to pesticides while working as a farmer. Which of the following would you expect to find on physical exam?
A. Bronchorrhea
B. Dry mucous membranes
C. Mydriasis
D. Tachycardia
Organophosphates! SLUDGE
A 32-year-old woman presents with vomiting and abdominal pain. She reports taking 40 acetaminophen tablets (500 mg each) in a suicide attempt 24 hours prior to arrival. Which of the following sets of laboratory results would be most consistent with hepatotoxicity secondary to acetaminophen overdose in this patient?
A. Alkaline phosphatase 550 U/L, gamma-glutamyltransferase 250 U/L, total bilirubin 4.7 mg/dL
B. Aspartate aminotransferase 280 U/L, alanine aminotransferase 130 U/L
C. Aspartate aminotransferase 4,600 U/L, alanine aminotransferase 3,200 U/L, alkaline phosphatase 140 U/L
D. Aspartate aminotransferase 5,800 U/L, alanine aminotransferase 6,300 U/L, total bilirubin 4.0 mg/dL
C. Aspartate aminotransferase 4,600 U/L, alanine aminotransferase 3,200 U/L, alkaline phosphatase 140 U/L
A 44-year-old man with diabetes presents after a fall. His family states he drinks alcohol every day, and no one has heard from him in 3 days. He is tachycardic and hypertensive with otherwise normal vital signs. He has no traumatic findings on examination but does have dried blood in his beard. Laboratory analysis reveals an elevated osmolar gap. Which of the following combination of findings suggests isopropanol toxicity?
A. pH 7.20, sodium 124 mEq/L, chloride 100 mEq/L, bicarbonate 6 mEq/L, and ketonemia
B. pH 7.32, sodium 135 mEq/L, chloride 95 mEq/L, bicarbonate 12 mEq/L, and no ketonemia
C. pH 7.40, sodium 140 mEq/L, chloride 105 mEq/L, bicarbonate 25 mEq/L, and ketonemia
D. pH 7.51, sodium 150 mEq/L, chloride 112 mEq/L, bicarbonate 28 mEq/L, and no ketonemia
C. pH 7.40, sodium 140 mEq/L, chloride 105 mEq/L, bicarbonate 25 mEq/L, and ketonemia
In the setting of an elevated osmolar gap, ketosis without a wide anion gap metabolic acidosis is the hallmark finding of isopropanol toxicity.
A 65-year-old man with a history of bipolar disorder and heart failure presents to the emergency department with acute tremors and confusion. He is unable to offer further history. His last known ejection fraction is 22%. He is currently on lithium. His T is 97°F (36.1°C), BP is 105/60 mm Hg, HR is 124 bpm, RR is 19/min, and SpO2 is 98% on room air. Physical examination reveals lower extremity pitting edema. A serum lithium level is 4.7 mEq/L, and his creatinine is 2.2 mg/dL. Which of the following is the most appropriate treatment?
A. Holding lithium and admitting for observation and serial exams
B. Nephrology consult for emergent hemodialysis
C. Normal saline boluses and admission for monitoring
D. Ringer lactate boluses and admission for monitoring
B. Nephrology consult for emergent hemodialysis
A 54-year-old man presents via EMS after an intentional overdose. His spouse found him at home, confused and covered in emesis. He was last seen at his baseline 4 hours prior. He has a history of hypertension, hyperlipidemia, diabetes mellitus, and depression. He takes pravastatin, lisinopril, diltiazem, metoprolol, metformin, and sertraline. His initial vital signs include an HR of 31 bpm, a BP of 90/31 mm Hg, an RR of 14/min, an SpO2 of 94% on room air, and a T of 37.1°C. A fingerstick glucose is 298 mg/dL. He is awake, is protecting his airway, and reports significant nausea. Physical exam reveals bradycardia, no murmurs, clear lungs, and intact cranial nerves. There is no clonus or rigidity. Two large-bore intravenous lines are placed, and a 20 mL/kg normal saline bolus is given. A dose of atropine is given. A repeat HR is 34 bpm, and a BP is 95/45 mm Hg. What is the most appropriate pharmacologic intervention?
A. Activated charcoal
B. Insulin and dextrose
C. Methylene blue
D. Sodium bicarbonate
B. Insulin and dextrose
CCB poisoning
Crystalloid-based intravenous volume resuscitation should be given early with caution to avoid fluid overload. Administering an IV bolus of high-dose insulin with a dextrose IV infusionprovides positive inotropic effects that improve cardiac output in overdoses of CCBs that are primarily causing cardiac suppression rather than a predominant vasodilatory shock state
A 23-year-old man is brought to the emergency department by his parents when he was found obtunded at home. He has a history of polysubstance use disorder. His T is 97°F (36.1°C), BP is 115/80 mm Hg, HR is 62 bpm, RR is 10/min, and SpO2 is 94% on room air. The patient does not respond to verbal stimuli but localizes to painful stimuli. He snores on occasion while in the ED. His pupils are 3 mm, round, and reactive. He has normal bowel sounds and no signs of trauma. Which of the following is the most appropriate management?
A. Flumazenil
B. Intubation
C. Naloxone
D. Observation on end tidal CO2
D. Observation on end tidal CO2