I Lost on Jeopardy, baby...ohhh..oh....oh...ohhh

Medic Phone

100

Which of the following is true following neck trauma?......a) Delayed neurological deficits after blunt trauma suggest CA dissection.......b)all patients suspected of having an esophageal injury should received barium contrast esophagram.......c) Zone III injuries are most amenable to surgical exploration.......d)all neck wounds should be probed to determine depth o wound and integrity of vital structures......e)impaled objects should always be removed with penetrating neck trauma

A......Delayed presentation of neuro deficits are characteristic of blunt vascular trauma. Only 10% will present in first hour, most will have stroke-like symptoms in 1-24 hours, and some still later. This is usually from dissection or thrombosis. esophageal injuries are uncommon, but water-soluble contrast like gastrograffin should be used not barium 2/2 to inflammatory mediastinitis is there is injury. Zone II are most amenable to exploration 2/2 to ease of exposure and vascular control. ALL neck wounds should be explored in the OR. If platysma violation can not be established, surgery should be consulted. NEVER remove a an impaled object out of OR.

200

17 y/o male presents with L knee pain after falling skiing. What is the most sensitive physical exam test for ACL Tear? ......a) Ant Drawer ......b) Post Drawer ......c) Lachman ......d) McMurray ......e) Thompson

C..........ACL is the most common injured ligament requiring surgery. Dx is often on Hx with with a "POP" after lateral or twisting force. Lachman place the knee in 20-30% flexion and pulling ant on leg stabilizing the thigh. Ant Drawer is not as sensitve, Post Drawer is for the PCL, McMurray is for the medial meniscus, and Thompson is for achilles

300

"Hard" findings of vascular injury mandating immediate angiography after trauma to an extremity include......A) non-pulsatile hematoma......B) Palpable Thrill.......C) Associated peripheral nerve deficit......D) Diminished pulse......E) All of the above.

B.........."Hard" signs strongly suggest vascular injury. Expanding hematoma, pulsatile blood loss, palpable thrill, audible bruit or combination of "5 P's" pain, parathesia, pallor, pulseless, paralysis) Thrills are uncommon though, but highly suggestive. "Soft" signs are non-pulsatile hematoma, diminished distal pulse, peripheral nerve deficit (ABI for LE is controversial)

400

Which of the following spinal injuries is most likely to be stable?......A) Flexion Teardrop......B) Bilateral Facet D/L......C)Tranverse Process Fracture.......D) Hangman's Fracture......E) Jefferson's Fracture

Spinal injuries are classified by mechanism and mechanical stability in reference to potential spinal cord injury. Unstable usually require surgical stabilization and likely to cause spinal cord damage. More common stable fractures are easy to remember, wedge fracture, spinous and transverse process fracture, vertebral burst fracture (WITH EXCEPTION OF C1 or JEFFERSON FX) all others are unstable to potentially unstable. Jefferson is vertical compression fracture, Hangman's now MVC usually is bilateral C2 pedicle fractures and C2 and C1 d/l from extension, Teardrop fracture is where the ant portion of body shears away causing ligamentous damage, B Facet d/l very unstable flexion injury where inferior facets of vertebra loose articulation with superior facets of inferior vertebra

500

16 y/o male presents after being struck in the face with a baseball. He complains of immediate vision loss and eye pain. Which finding is most concerning for underlines globe rupture?......A)Hyphema......b) Subconjunctival Hemorrhage......C) Marked decrease visual acuity......D) Orbital floor fracture......E) Bloody Chemosis

C......Hyphema and subconjunctival hemorrhage are often present w/o rupture. Orbital wall fractures often occur w/o rupture. Bloody chemises is a result from severe subconjunctival hemorrhage. All of these can occur with globe rupture, but in all visual acuity is usually retained

Hey Tim..????

100

Which is true regarding acute ASA toxicity treatment?......A) urinary pH of 7.5-8 is desirable......B) Forced diuresis is an effective adjunct therapy......C) Activated Charcoal is ineffective......D)Whole bowel irrigation is contraindicated......E) Hemodialysis has not role

A......Tx includeds GI Decontamination, hydration, and enhanced excretion. Urinary alkalinization with Sodium Bicarb promotes excretion. Forced diuresis is associated with cerebral and pulm edema. Whole bowel irrigation and Activated charcoal with enteric coated and acute ingestions respectively. HD is needed in failure of standard non-invasive therapy, or severe toxicity

200

Which of the following opoids may predispose to serotonin syndrome?......A) Fentanyl......B) Meperidine......C) Propoxyphene.......D)......Hydrocodone......E) Morphine

B......Meperidine may cause SS in pt's taking SSRI's. MAOI's. Dextromethorphan can also do this. SS physical s/sx's:agitation, ataxia, diarrhea, hyperreflexia, mental status changes, myoclonus, shivering, tremor, or hyperthermia

300

4 y/o boy presents after ingestion of his grandmother's antihypertensive medication. He is sleepy, bradycardic, and hypotensive. Which is the most appropriate treatment?......A) Atropine......B) Glucagon......C)Atropine and glucagon......D) Atropine, Glucagon, Calcium......E) Atropine, Glucagon, Calcium, and high-dose insulin with glucose

E......Overdose with HTN medication causing bradycardia, hypotension, and depressed mental status is likely from CCB, or Beta-Blocker. Insulin and Glucose is suggested in Beta Blocker Toxicity. (This could also be Clonidine would need to crystalloids, pressors, and possibly charcoal)

400

Which of the following toxins is suggested by the smell of garlic?......A) Cyanide......B) Zinc......C) Toulene......D) Organophosphate......E)......Hydrogen Sulfide

D......Garlic is associated with Organophospate (also arsenic or selenium. Sulfide (rotten eggs), Toulene (Glue), Zinc (fishy), Cyanide almonds. Don't forget SLUDGE or DUMBELLS and diaphragmatic failure from nicotinic, and aggressive atropine.

500

Which of the following best distinguishes patients with serotonin syndrome from patients with other drug or toxin-related effects?......A) Tachycardia......B) Clonus......C) Shivering......D) Hyperthermia......E) Muscular rigidity

B.........SS is classically triad of autonomic hyperactivity, cognition abnormalities, neuromuscular problems. There is considerable overlap with with NMS, and Anticholingergic syndrome. Clonus is the most important difference. It may be spontaneous, inducible or isolated, to the ocular muscles

It's Not About Earthday

100

16 y/o male was camping in Texas when he was bitten by a "brightly Colored" snake. A friend took an picture on his iphone and your colleague told you it was a coral snake. The pt is c/o only very minimal pain and swelling at the site. What is your next best step?......A) Pt should be observed for a minimum of 6 hours......B) The patient should immediately receive CroFab.....C) Wound should be irrigated with sterile saline, and a sterile suction catheter placed to remove venom......D) pt should immediately receive North American coral snake antivenin......E) Patient should receive IM mix of antivenin close to the site as possible

D......The pt was bitten by a NA coral snake. (you can tell by red touches yellow kills your PEM fellow, red touches black venom lack). All patients get antivenin. Coral snakes venom can be fast or delayed with neurotoxicity, nausea, delirium, drowsiness, tremors, hyper salivation CN abnl, and respiratory failure

200

A 4 y/o touches an exposed wires of a socket. Which is true regarding electrical injury?.....A) C is more dangerous than AC......B) High-voltage injuries, the extent of cutaneous injury is is a good predictor of internal injuries......C) Asystole is the the most common cardiac dysrhythmia resulting from low-voltage injuries......D) In contrast to other mass casualty events, patients without signs of life should be resuscitated first......E) all of the above

D..........For a given voltage, AC is thought to be 3 times more dangerous. High Voltage injuries should be treated like crush injuries due to likelihood of tissue damage below the normal appearing skin, it is impossible to determine underlying damage from skin. Low-Voltage causes dysrhythmia in less than 10%. If dysrhythmia occurs, it is usually V-Fib. Because of good outcomes, pt's with no SOL after high-voltage injury should be resuscitated with CPR and De-fib

300

15 y/o boy is brought in after being submerged in a lake for "1-2 minutes" He had been water skiing and "wiped out" then laying face down in the water. He was not breathing when his friend pulled him from the water, but he regained spontaneous respirations after CPR. In the ED, he is awake but somnolent, breathing spontaneously, sating 95% on RA, making spontaneous movements, and following commands. Next step in management is:......A) IV ABX......B)RSI......C) IV Dexamethasone......D) C-spine films......E) ED thoracostomy

D......Trauma in setting of submersion injuries are usually 2/2 to MVC into water, or diving, boating, falls. ABX have no role in fresh or saltwater immersion. Steroids have no role unless previous RAD with evidence of bronchospasm. RSI is not presently indicated.

400

You are in the Himalayas as volunteer doctor, and you hear over the radio of an intrepid 17 y/o male who wants to be the youngest climber to summit Mt. Everest. He develops h/a, nausea, and dizziness while hiking at 10,000. His next base camp is 100 yards away and it has acetazolamideand dexamethasone. What is the next best step?.....A) set up tent and sleep at the current altitude for the night......B) Continue to the cabin......C) Descend 1,500 to 2,000 feet until symptoms improve......D) Stimulate hypoxic ventilatory response with energy drink......E) All above are reasonable

C......Pt has acute mountain sickness which is characterized by h/a, GI symptoms, fatigue, dizziness, difficulty sleeping. Key principle is further ascent is contraindicated since symptoms cannot predict clinical course. If symptoms are mild, and shelter and treatment are available, staying put is an option, but descent is most effective treatment

500

EMS calls, there is a mass casualty alert. At the local high school basketball game, the fans became ill, several slumped to the ground, some seemed to have loss of consciousness, and some are "convulsing". Patients who are walking in are c/o headache, shortness of breath with a "frothy cough", lots of "spit", runny nose, nausea, vomiting, achiness. Some noted an odorless mist from the vents. The patients are on high flow oxygen. What is the next best course of action?......A) Pralidoxmine (PM) and atropine......B) Amily Nitrate......C) Sodium Thiosulfate and sodium nitrate......D) Diazepam and atropine......E)Succinylcholine and etomidate and intubation

A......This is a cholinergic response. The vignette suggests organophosphate nerve agents. Think SLUDGE/DUMBELS. Atropine should be started immediately and titrated until there are no longer any respiratory effects.PM should be given liberally as well to counter act the nicotinic effects (flaccid paralysis, fasciculations, muscle weakness). DO NOT use such, prolonged paralysis, and thiosulfate and nitrate can be used for cyanide.

MMMMM...Potluck Dinner!

100

Which is the most common dysrhythmia is pediatric patients?......A) a-fib......B) A-Flutter......C).....Complete Heart block......D) PSVT......E)......V-Tach

PSVT

200

15 y/o male presents with shortness of breath and nausea. He states he has been "huffing glue". Which is the most appropriate therapy at this time?......A) Supportive......B) ABX......C) Corticosteriods......D) Diuretics......E) Activated Charcoal

A......Management of hydrocarbon toxicity is generally supportive. Hydrocarbons usually cause plum toxicity and cardiac dysrhythmias. Most common is inhalation through "huffing" paint or glue.

300

A concerned mother brings in her 15 y/o daughter with irregular vaginal bleeding. Pt experience menarche at 13 and has never had regular periods. Recently, her bleeding has been heavier and more irregular recently. No h/o easy bruising and no evidence of petechiae. Her hemoglobin is 11. Which is most likely the cause of her symptoms?......A) Hyperthyroidism......B) Anovulation......C)Endometriosis......D) Asymptomatic Chlamydia......E) Halban's disease

B.....DUB is a is defined as excessive, prolonged or erratic uterine bleeding not associated with underlying anatomic defect or systemic disease. Therefore it is a dx of exclusion. The most common adolescent cause of irregular bleeding is anovulation. This usually last 2-3 years but can last unto 6. Oral contraceptive therapy is very effect with some combination of estrogen and progesterone

400

9 y/o boy presents with 3 days of progressively worsening R eyelid swelling, pain and redness. He denies blurry vision. Which of the following is more characteristic of orbital vs periorbital cellulitis?......A) Fever......B) Periorbital edema......C) Eyetenderness......D) S. aureus is the etiological agent......E) Restricted eye movement

E..........pt's with preriorbital (preseptal) cellulitis may have fever, periorbital edema, and eye tenderness. But, Ophthmalmoplegia is characteristic of orbital cellulitis. Gram + cocci are in both, but S. aureus is usually periorbital. Orbital is usually Strep pneumo, H. flu, Strep progenies, polymicrobial. Dx. can be definitively made with CT of orbits and brain, Orbital cellulitis mandates input IV abc

500

What is the clinical factor that best differentiates heat stroke from heat exhaustion?......A) Core temp > 102......B) Presence of anhidrosis......C) Elevation of hepatic enzymes......D) CNS dysfunction......E) H/O exertion in hot environment

D.......Neuro Dysfunction is the hallmark of heatstroke. Exhaustion can presents with malaise fatigue, h/a, nausea, vomiting, impaired judgement. Heat stroke is usually above 105 with evidence of organ failure. Both can have elevated transaminases. Most significant, heat stroke patients can have delirium, seizures or "coma".

I...Can't...Breath

100

13 y/o boy presents to the ED with his mom with a 3-week cough what "won't go away". She asks if he has walking pneumonia. Which is true?.......A) Walking pneumonia may frequently be caused by Chlamydia pneumonia, a sexually transmitted organism......B) This is usually caused by EBV, the same virus that causes mono, and will last several weeks.....C) The pt needs to be admitted to the PICU for IV abx before it progresses to respiratory distress.....D) The most common causes are Mycoplasma and C. Pneumoniae and macrolides are the abx of choice......E) A clear chest xray makes walking pneumonia less likely

D...... Walking pna is most often caused by the "atypical" organisms like mycoplasma, C pna, and legionella, unlike the typical strep pna. Pts are usually well enough to function on a daily basis. Studies show it is not possible to distinguish walking vs typical pna by symptoms and xray. However, in his age group, the atypicals are most common so empiric tx with macrolides are reasonable for first tx option.

200

What is the half-life of carboxyhemeglobin with 100% oxygen nonrebreather mask?.......A) 6 hours......B) 3 hours.......C) 90 minutes.......D) 60 minutes......E) 30 minutes

C..........6 hours on RA, 90 minutes on non-rebreather, 30 minutes in hyperbaric chamber

300

7 y/o female presents with her father after choking on a plastic toy. She was coughing and gasping violently in the car ride over. The father attempted the heimlich maneuver and blind finger swipe. And, she seemed to get worse. The pt is now in your ED cyanotic, and unconscious. You perform a jaw-thrust maneuver, but you do not see a foreign body. You attempted endotracheal intubation, but seem to be striking an object. What is your next best step?......B) Laryngeal mask airway......B) Surgical cricothryoidotomy......C) Back blows to dislodge the FB.......D) Blind finger swipes to removed FB......E) Needle cricothyroidotomy

E..........This patient has a complete airway obstruction. This patient went from a partial to complete FB aspiration. Back blows and chest thrusts are reasonable in initial response. Blind finger swipes are not recommended as this might make a partial obstruction become a complete obstruction. Since this patient is younger than 8, so therefore would need a needle cric instead of a surgical. Using a 12 or 16 gauge angiocath, insert it into the inferior portion of the cricothyroid membrane. Attach this to a 3.0 ETT adapter and use a bag or jet insufflation. These are only temporary

400

Which of the following statements regarding FB inspiration is correct?.......A) Most aspirated FB are radio-opaque......B) Children younger than 12 months more commonly have a delayed presentation......C) Most foreign bodies are aspirated into the tracheae instead of the more distal airways......D) obstructive emphysema is one of the most common radiology findings......E) Persistent cough is the most predictive of finding a FB aspiration

D..........Most FBs are vegetable in origin and radioluscent. Most common radiologic findings is unilateral obstructive emphysema 2/2 to a one way valve. Studies show that R or L bronchus is more common than the trachea, but statistically the classical teaching of R main stem does not necessarily bear out. Children under 12 months usually present more acutely because of small airways, but older children can present more subacute because of "low-level" symptoms. Ages 1-3 are the children at highest risk. Most common predictive finding is witnessed aspiration with choking.

500

You have just finished placing a chest tube in a 17 y/o with a 25% spontaneous pneumothorax. You consult CT surgery as that ask is the is an "air leak". Assuming the lung has re-expanded properly, was is the most likely significance of the air leak?......A) all pts have an air leak after chest tube insertion......B) the tube was placed in a branch of the tracheobroncial tree......C) suction holes are not completely inserted in the cavity......D) water seal chamber does not have enough water in it......E) the is an unhealed defect in the bronchial tree

E..........Tube thoracostomy is the most common procedure in the setting of thoracic traumatic. It is the primary treatment for primary or secondary PTX. After placement, the air in the pleural space is evacuated, but the bronchial defect is not yet healed so the suction is pulling from the actual bronchial system. The idea is that the defect is slower than the suction maintaining lung expansion. Once the defect is assumed healed, the patient is asked to cough. When the pt coughs, the increase in intrathoracic pressure and will force air through the defect if still there. If it is a cause of the chest tube system, the lung will not expand as properly, and there will be constant bubbling in the water tube.