Trauma
Which of the following is the most common location of traumatic aortic injury?
A. Aortic arch between the left common carotid and the left subclavian arteries
B. Aortic isthmus immediately distal to the left subclavian artery
C. Ascending aorta immediately proximal to the brachiocephalic artery
D. Descending aorta immediately distal to the diaphragm
B. Aortic isthmus immediately distal to the left subclavian artery
This is thought to be due to the isthmus being the transition zone between the mobile ascending aorta and the more fixed thoracic aorta. Most aortic injuries are fatal before hospital arrival.
What is the best next step in management of 2 year old with suspected nurse maid's elbow?
A. Elbow extension then supination
B. Hyperpronation then elbow flexion
C. Supination then elbow flexion
D. Supination then hyperextension
C. Supination then elbow flexion
Two most common techniques used to reduce radial head subluxations include hyperpronation with the elbow at around 90° and supination with elbow flexion
Which of the following would indicate that a patient with PE is unsafe for discharge and outpatient treatment based on the Hestia criteria?
A. Blood pressure of 162/92 mm Hg
B. Creatinine clearance of 40 mL/min
C. Current use of apixaban for atrial fibrillation
D. History of COPD
E. Oxygen saturation of 96% on room air
C. Current use of apixaban for atrial fibrillation
Other indications = Tachypnea, Tachycardia, Hypoxia, High risk of bleeding, Pregnant, Cr Clearance < 30
TM Rupture is an example of what type of blast injury?
A. Primary
B. Secondary
C. Tertiary
D. Quaternary
A. Primary
Which of the following provides definitive treatment for a tension pneumo?
A. Needle decompression
B. Chest tube thoracostomy
C. Intubation
D. Bipap
B. Chest tube thoracostomy
Needle decompression is not the definitive management, though may be next best step
32-year-old M s/p MVC intubated at the scene for depressed mental status. His vital signs on arrival are HR 38 bpm, BP 62/40 mm Hg, T 36.2°C, and RR 14/min on mechanical ventilation. His extremities are warm, well-perfused, and without obvious deformity. His exam is otherwise significant only for widespread road rash. Which of the following is the most likely cause of the patient’s hypotension?
A. Cardiogenic shock
B. Hypovolemic shock
C. Distributive shock
D. Obstructive shock
C. Distributive shock
Neurogenic Shock
Hydrofluoric acid burns result in:
A. Hypercalcemia, hypermagnesemia, hypokalemia
B. Hypercalcemia, hypomagnesemia, hyperkalemia
C. Hypocalcemia, hypermagnesemia, hypokalemia
D. Hypocalcemia, hypomagnesemia, hyperkalemia
E. Hypocalcemia, hypermagnesemia, hyperkalemia
D. Hypocalcemia, hypomagnesemia, hyperkalemia
Give calcium gluconate! Topical first, can consider intra-arterial or IV with Bier block
22 month old M presents with fever, cough, dyspnea for 2 days. On exam saturating 96% on room air with nasal flaring and intercostal retractions with wheezing and crackles bilaterally. He is lying on his parent's chest, tired. Best next step?
A. Corticosteroids
B. High flow oxygen
C. Nebulized albuterol
D. Nebulized hypertonic saline
B. High flow oxygen
Bronchiolitis most commonly RSV
A body being thrown from explosion into a wall is an example of what type of blast injury?
A. Primary
B. Secondary
C. Tertiary
D. Quaternary
C. Tertiary
What is the best treatment for a patient with AIDS with PCP PNA, SPO2 93%, PaO2 75 and A-a gradient of 30?
A. Bactrim & Steroids
B. Bactrim
C. Azithromycin
D. Bronchodilators & Steoids
B. Bactrim
Add steroids if PaO2 < 70 or A-a gradient > 35
In patients with a suspected tripod fracture, what is the mainstay of emergency evaluation?
A. CT Head
B. CT Face
C. CT Ankle
D. CT Hip
B. CT Face
Lateral orbit, zygoma and maxilla fractures. This leads to free movement of the zygoma. Fractures with significant malar eminence flattening or vision changes should receive antibiotics (Unasyn) after emergent Plastics / OMFS consult
25 yo M presents to the ED s/p electrocution while at work. He has experienced muscle spasms, cramping, and pain since the episode. Tachycardic but otherwise vitals WNL. PE reveals diffuse muscle tenderness. Lab values are notable for K 6.0 mEq/L, Ca 6.8 mEq/L, Cr 1.9 mg/dL, and Phos of 5.1 mg/dL. Which of the following is the most appropriate treatment for this patient?
A. Furosemide
B. Nephrology consult to initiate dialysis
C. Normal saline bolus
D. Ringer lactate bolus and sodium bicarbonate ampule
C. Normal saline bolus
Attempt fluids prior to dialysis. Not hyperkalemic or renal failure enough based on labs. Bicarb shows no benefit
Which of the following most strongly predisposes a patient to ARDS?
A. Acute myocardial infarction
B. Hyperglycemia
C. Pulmonary embolism
D. Sepsis
E. Valvular heart disease
D. Sepsis
Major risk factors = Sepsis, PNA, Aspiration, Severe Trauma including Burns
Smoke inhalation is an example of what type of blast injury?
A. Primary
B. Secondary
C. Tertiary
D. Quaternary
D. Quaternary
Employee at a local restaurant mixes two common cleaning agents together to make a cleaning solution. Everyone present reports immediate eye burning and upper respiratory tract irritation. Employee presents to ED with significant coughing & respiratory distress, which subsides with time & humidified O2. Inhalation of which of the following is most likely responsible?
A. Ammonia
B. Bleach
C. Chloramine
D. Phosgene
C. Chloramine
Bleach & Ammonia together create highly water soluble irritant leading to severe symptoms
23 yo M presents 6 hrs s/p assault hit in face multiple times without LOC. ROS only + for nasal pain. The bridge of his nose is swollen with mild tenderness and dried blood is in his nares with intact, pink septum. He has no other bony tenderness or evidence of trauma. What is the appropriate next step in management?
A. Attempt closed reduction of the presumed nasal fracture
B. Computed tomography of facial bones
C. Discharge with otolaryngology follow-up in 7–10 days
D. Lateral facial bones X-ray
C. Discharge with otolaryngology follow-up in 7–10 days
Do not need imaging of nose if:
1. Tenderness /swelling isolated to bony nasal bridge
2. Patient can breathe thru each nares
3. Nose is straight / no septal deviation
4. No septal hematoma
14 yo M presents s/p MVC with chest wall ecchymosis & tenderness. Saturating 89% on nonrebreather. CXR shows pulmonary contusions. What is next best step in management?
A. Chest Tube
B. ECMO
C. Nitro & Lasix
D. Intubation with affected lung down
E. Intubation with affected lung up
E. Intubation with affected lung up
In hemothorax you want affected lung down. In pulmonary contusion you want affected lung up to optimize oxygenation
What is the maximum volume of intrathoracic blood that may be missed on a supine chest X-ray?
A. Up to 1,000 mL
B. Up to 200 mL
C. Up to 500 mL
D. Up to 700 mL
A. Up to 1,000 mL
500 mL should be seen on upright but can be missed on flat CXR due to blood pooling in posterior aspects
Which of the following is an example of a secondary blast injury?
A. TM Rupture
B. Burns
C. Amputations
D. Radiation
C. Amputations
Secondary = Impact of fragments from exploding device or fragment
56 yo F presents with SOB. Hx of HLD and OCP use. HR of 121 bpm, BP of 124/80 mm Hg, RR of 24/min, T of 37.2°C, and SpO2 of 89% on room air. Her ECG shows sinus tachycardia. CTA of the chest shows a segmental pulmonary embolism. Which of the following represents her PE risk score?
A. Very low
B. Low
C. Intermediate
D. High
E. Very High
C. Intermediate
Age 56 + 20 for HR > 110 & +10 for hypoxia < 90% = 96 points
Which of the following may be seen in Le Fort II Fractures?
A. Cerebrospinal fluid rhinorrhea
B. Frontal bone displacement
C. Movement of the hard palate without nasal movement
D. Traction on the optic nerve
A. CSF Rhinorrhea
Speak no evil, See no evil, Hear no evil
10 yo M presents s/p unrestrained high-speed MVC. Awake & alert without obvious head or major extremity injuries. Vitals WNL s/p fentanyl. Moderate flank tenderness on exam, and his urine shows gross hematuria, despite a normal pelvis X-ray. Which is the best imaging study to perform in this patient?
A. Abdominal CT with additional delayed scan
B. Focused assessment by sonography for trauma
C. Intravenous urography
D. Retrograde urethrogram
A. Abdominal CT with additional delayed scan
Best test to identify renal laceration. FAST does not identify. Retrograde urethrogram used if pelvic fx.
Renal cortex & collecting system in different timeframes on CT scan
7 yo M weighs 20 kg, has 10% full-thickness burns, 10% partial-thickness burns, and 10% superficial burns. How much IV LR should the patient receive in the first 8 hrs according to the Parkland formula?
A. 1,200 mL
B. 1,600 mL
C. 2,400 mL
D. 800 mL
D. 800 mL
Affected TBSA x Kg x 4 mL = 24 hrs LR with
1/2 in first 8 hours
Several people present to the ED after a nearby gas line explosion. In the presence of a perforated tympanic membrane, which of the following is the most appropriate next step in care?
A. Chest X-ray
B. Computed tomography of the head
C. Electrocardiogram
D. Otolaryngology consultation
A. CXR
Primary blast injury
Antibiotic coverage for patients with 17 yo F with cystic fibrosis lobar PNA? Tachycardic & Tachypneic
A. Azithromycin & Pulm f/u
B. Bronchodilators, steroids & Pulm f/u
C. Ciprofloxacin & admission
D. Vanco, Zosyn, admission
E. Vanco, Zosyn, Tobramycin & admission
E. Vanco, Zosyn, Tobramycin & admission
CF PNA requires broad spectrum coverage with double pseudomonal coverage typically including aminoglycoside