Psych / Opiates
What pulmonary complication can Narcan classically cause?
Pulmonary Edema
Narcan 0.4 mg IV or 4 mg IN. Consider 2-4mg IV in code or refractory situations with high suspicion, especially with nitrazines. Lasts 30-90 min, prepare for relapse.
If starting a drip - recs are starting infusion at 2/3 of the effective bolus dose per hour
Which of the following is most characteristic of a obese F with idiopathic intracranial hypertension?
A. Abnormal CSF chemistry analysis
B. Dense triangle sign on CT scan of the head
C. Opening pressure of 20 cm H2O on LP
D. Transient visual loss
E. Unilateral papilledema
D. Transient visual loss
Should be normal CSF. Dense triangle seen in cerebral venous thrombosis. Normal opening pressure 20 or less or 25 in obese individuals. Papilledema should be BL.
34 yo F presents with fever, AMS, HA and neck stiffness. What is the next best step?
A. Lumbar Puncture
B. Antibiotics
C. CT Head
B. Antibiotics
Empiric Abx if must obtain CT head prior to LP to not delay care.
Abx, CT head, then LP. Vanc, Rocephin & Dex if concern for Meningococcal meningitis
Must obtain CT head prior to LP if:
- AMS, Focal neurologic deficit, signs of increased ICP (papilledema)
3 year old with autism presents with recurrent AOM. Refuses to take PO meds despite attempts. Afebrile and well-appearing without mastoiditis. Most appropriate tx option if parents are adherent?
A. Augmentin
B. IM Rocephin daily x3
C. IV Rocephin
D. Cefdinir
B. IM Rocephin daily x3
Try to avoid admitting this kid. Autistic children refusing PO meds very common. IM Rocephin widely used alternative. Cefdinir used PO for AOM refractory to augmentin alternative but same issue PO here.
Patient undergoes LP for IIH. Which of the following would most likely decrease the incidence of a postdural headache for this patient?
A. Caffeine supplementation prior to lumbar puncture
B. Instructing the patient to lie flat for 1 hour after the procedure
C. Inserting the needle bevel parallel to the direction of dural fibers
D. IV fluid supplementation during and after the procedure
C. Inserting the needle bevel parallel to the direction of dural fibers
Laying flat not shown to decrease HA
Which of the following properties of buprenorphine is responsible for precipitating withdrawal symptoms if the medication is given to a patient acutely intoxicated with opiates?
A. High-affinity agonism
B. Long half-life
C. Receptor antagonism
D. Short half-life
A. High-affinity agonism
Partial agonist that prevents other opioids from binding. Can precipitate withdrawal if actively intoxicated.
26-year-old F on OCPs presents with HA for 1 week with nausea, vomiting, and blurred vision. PE shows papilledema and a cranial nerve IV palsy. Which of the following is the most appropriate diagnostic test?
A. CT angiography
B. Fluorescein staining of the cornea
C. Magnetic resonance imaging and venography
D. Noncontrast CT scan of the head
C. Magnetic resonance imaging and venography
Cerebral venous sinus thrombosis
Meds for meningitis in neonate with hyperbilirubinemia?
A. Vancomycin, Rocephin
B. Ampicillin, Gentamicin, Rocephin
C. Ampicillin and cefotaxime
D. Vanco, Rocephin, Ampicillin
C. Ampicillin and cefotaxime
A is correct for age 18-50. B would be correct minus Rocephin can't give in neonates with hyperbilirubinemia. D is correct in people age > 50
6 month old immunized F presents with cellulitic diaper rash. Hx of recurrent pus-filled boils. Afebrile and well-appearing. Abx of choice?
A. Keflex
B. Doxycycline
C. Clindamycin
D. Vancomycin
C. Clindamycin
Need MRSA coverage. No doxy in kids except in RMSF. Vanco not necessary in afebrile well-appearing
51-year-old F Type II DM presents with pain & swelling of the face that began yesterday. Her symptoms began abruptly with a high fever & chills. PE shows bright red indurated skin in a well-demarcated malar distribution. Most appropriate treatment?
A. Intravenous ceftriaxone
B. Oral amoxicillin
C. Oral prednisone
D. Topical metronidazole
A. Intravenous ceftriaxone
Dx = Erysipelas. Given hx of DM, better for IV abx in septic patient sepsis. Typically caused by S pyogenes
Mild cases without purulence or systemic signs can be treated with a 5–6 day course of oral antibiotics such as cephalexin, dicloxacillin, or clindamycin
Topical flagyl for Rosacea
In which of the following scenarios would initiating buprenorphine be the precipitant of acute opioid withdrawal in the patient?
A. A patient who injected fentanyl 6 hours ago
B. A patient who took tramadol 18 hours ago
C. A patient who used methadone 24 hours ago
D. A patient who used methylnaltrexone 12 hours ago
C. A patient who used methadone 24 hours ago
Recommended initial dosing of Buprenorphine is 4–8 mg sublingually. After 30–60 minutes, if clinical withdrawal is still present, an additional 8–24 mg can be administered with a target of 16 mg for most patients
60 yo F presents with difficulty with ambulation for 3 days. Vitals WNL & Labs unremarkable including ESR. PE shows 0/5 strength in bilateral lower extremities that are notably flaccid, numbness in the perineum, and paresthesias and numbness noted encircling the abdomen at the level of the umbilicus. PVRV 400.
A. Cauda equina syndrome
B. Guillain-Barré syndrome
C. Spinal epidural abscess
D. Transverse myelitis
D. Transverse myelitis
Sensory level with rapidly progressive flaccid paralysis that progresses to spastic paralysis.
Cauda equina should have hx of LBP or CA and no sensory level.
1 week old presents with fever. Which is most likely causative organism of meningitis?
A. S pneumo
B. N meningitidis
C. Pseudomonas
D. E coli
E. S aureus
D. E Coli
Group B strep & Listeria also common with E coli in neonates. S pneumo most common after 1 month.
38-week gestational age F presents immediately after birth. She was born precipitously in ambulance bay. Which of the following, if present, is the best indicator to determine whether the infant needs resuscitation?
A. Acrocyanosis
B. Apgar score of 4
C. Heart rate of 90 bpm
D. Oxygen saturation of 75%
C. HR < 100 requires neonatal resuscitation
O2 sat normal with 75% at 3-4 min of life will increase from 65% at birth to 95% at 10 min. Acrocyanosis normal & APGAR does not guide resuscitation
Patient receiving IV Vancomycin receives reports intense pruritus & lightheadedness after 10 min of infusion. Erythema is noted on his face & neck, and his lungs are clear to auscultation. Vitals BP of 110/70 mm Hg, HR of 110 bpm, RR of 20/min, T of 99.9°F, and SpO2 of 98% on room air. Best next step in management?
A. Administer IM Epi & decrease the rate of the infusion
B. Administer IM Epi & suspend the infusion
C. Administer IV benadryl & decrease rate of infusion
D. Administer IV benadryl & suspend the infusion
D. Administer IV benadryl & suspend the infusion
Most common risk factor for PTSD?
A. Exposure to organized violence
B. Life-threatening traumatic event
C. Participation in organized violence
D. Sexual relationship violence
D. Sexual relationship violence
Most common = sexual assault & intimate partner violence. Life threatening ~10%
A woman is brought to the ED for an acute stroke. She was asymptomatic 2 hours ago then developed left arm & facial weakness. Which of the following excludes her from receiving thrombolytic therapy?
A. Age > 75 years
B. Failure to understand risks and benefits
C. International normalization ratio 1.5
D. Multilobar and extensive infarcts on head CT
E. Systolic BP 181
D.Multilobar and extensive infarcts on head CT
Hypodensity that involves greater than one-third of a cerebral hemisphere is a contraindication for intravenous thrombolytic therapy in acute stroke.
Age not absolute contraindication except < 18.
INR > 1.7 not 1.5
What are the criteria for a simple febrile seizure?
Include Age & Duration
Age 6 months - 60 months (5 years)
GTC activity < 15 min in setting of fever. Return to baseline. No more within 24 hrs.
Incomplete Kawasaki Dz - Next steps for diagnosis and treatment?
Dx = Order ESR & CRP if < 4 of criteria for Kawasaki are met but high clinical suspicio
Tx = ASA & IV IG
Tx for poison ivy contact dermatitis? Above & below a certain threshold of TBSA%
Topical steroids for < 10%
33-year-old M with schizophrenia treated with Haldol long-term presents to ED w/ involuntary, writhing movements of the tongue & face. Additionally, the patient has choreoathetoid movements of the trunk and arms. What initial management is indicated?
A. Benztropine
B. Diphenhydramine
C. Lorazepam
D. Tapering down haloperidol
D. Tapering down Haldol
Benztropine & Benadryl treat acute dystonia not tardive dyskinesia.
Reserpine and tetrabenazine have shown some benefit in combination with stopping the offending agent.
14 yo boy presents with fever, HA, and AMS. Had recent sinusitis. CT head shows a brain abscess. What is most appropriate treatment regimen?
A. Ceftriaxone, metronidazole, and hospital admission for monitoring
B. Ceftriaxone, metronidazole, and neurosurgery consultation
C. Ceftriaxone, vancomycin, and neurosurgery consultation
D. Dexamethasone and neurosurgery consultation
E. Pyramethamine, sulfadiazine, and hospital admission for monitoring
B. Ceftriaxone, metronidazole, and neurosurgery consultation
Cover with 3rd gen cephalosporin and anaerobes. Add MRSA coverage if hx of neurosurgery or trauma.
Most commonly occur due to dental infections, sinusitis or otitis media. Strep & anaerobes usually
18 yo M weighing 70 kg presents in status epilepticus refractory to 0.1 mg/kg IV Versed x3.
Which of the following is an appropriate next tx method while preparing for intubation if this fails?
A. Keppra 1G
B. Keppra 40 mg/kg
C. Valproate 20 mg/kg
D. Fosphenytoin 20 mg/kg
D. Fosphenytoin 20 mg/kg
Refractory status calls for benzos, followed by Keppra 60 mg/kg up to 4500 mg or Valproate at 40mg/kg or "FosPhenty Twenty" before preparing to intubate with propofol, versed or ketamine
Dx of Kawasaki includes a fever for 5 days PLUS 4 of which 5 criteria?
1. Bilateral bulbar conjunctival injection
2. Oral Mucosal Membrane Changes
3. Peripheral Extremity Changes
4. Polymorphous Rash
5. Cervical LAD
CRASH & Burn = Conjunctivitis, Rash, Adenopathy, Strawberry Tongue, Hand/foot edema
Patient with Guillan-Barre has SOB. Which one of the following indicates impending respiratory failure and high likelihood of endotracheal intubation?
A. Forced vital capacity 25 mL/kg
B. Forced vital capacity 40 mL/kg
C. Negative inspiratory force 25 cm H2O
D. Negative inspiratory force 40 cm H2O
C. Negative inspiratory force 25 cm H2O
Minimum FVC 20 mL/kg. Minimum NIF < 30 cm H2O