ER MEDICINE REVIEW1. Abdominal Pain

a. Pancreatitis (RANSONS criteria)b. Diverticulitis

i. LLQ,ii. Increased WBCiii. No bleeding

2. Esophageal rupture3. Boerhaves

a. Crepitus b. Hamans crunch

4. Pain out of proportion = ischemia (mesenteric)a. Have high index of suspiciaonb. Looks like drug abuse patientc. Risks- afib, protein/cns deficiency. Chf(low flow state)

5. Stomach tearingAAACT scan/US6. Funny sensation in leg Dissection

a. Artery of Adamkerwitz-lack of flow to spinal cord causeing sensory problems secondary to dissection

7. Perforated bowelmechanical volvulus ulcera. U/S for appendicitis

8. Ingestion of battery go get it9. Alcoholics – withdrawl asterixis (see in cirrhosis as well)

a. Can OD if you think alcoholic benzo b/c of 1st pass10. Bannana bag = multivitamins and thiamine (B1)11. ACLS12. Acute MI elevated S-T aspirin thrombolytic

a. The WHO criteria were refined in 2000 to give more prominence to cardiac biomarkers.[74] According to the new guidelines, a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI.

b. There are absolute and relative contraindications to thrombolytic therapy.Absolute[edit]

i. Previous intracranial bleeding at any time, stroke in less than 6 months, closed head or facial trauma within 3 months, suspected aortic dissection, ischemic stroke within 3 months (except in ischemic stroke within 3 hours time), active bleeding diathesis, uncontrolled high blood pressure (>180 systolic or >100 diastolic), known structural cerebral vascular lesion, arterio-venous malformations, thrombocytopenia, known coagulation disorders, aneurysm, brain tumors, pericardial effusion, septic emboli.

ii. The EKG’s marked ST-segment elevation in V1, in the absence of ST-segment elevation in the other anteroseptal leads (V2-V3), is suggestive of right-ventricular ischemia. Right-sided leads should be performed to further assess this possibility.

13. Drugs that can be put in ET tube LANE (lidocsine, atropine, naloxone, Epi)14. AICD is misfiring magnet changes it to a fixed pacer mode15. Contraindications for thrombolytics (not if cath is available) – aortic dissection, brain

bleed,16. Cardiac rhythm

a. V.tachb. V.fib

17. Don’t give nitroglycerins w/erectile dysfunction18. Kawasaki aneurysms give aspirin

a. Strawberry tongue, diffuse rash, injected conjunctiva19. Thoracic dissection

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a. Ripping pain to backi. Aortographyii. CT-Aiii. Transesophageal echoiv. CXR – see loss of AP windoe, widened mediasteinym, deviation of

tracheav. CT of the chest is the test most often used to confirm the diagnosis of

aortic dissection. CT is readily available in most Emergency Departments, and has a sensitivity of 83-98% and specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits associated with the use of CT include the ability to identify intramural thrombus, pericardial effusion, and potentially reveal another etiology for the patient's pain. The major disadvantage of CT is the need for iodinated contrast, which requires normal renal function.”

vi. When a patient has an aortic dissection, it is important to decrease further dissection (i.e. extension of the vascular tear) by reducing shearing forces on the aorta using negative inotropes (beta blockers) and to control hypertension. Sodium nitroprusside is often used for blood pressure control in dissections as it is an easily titratable antihypertensive. Because sodium nitroprusside increases heart rate and may increase shearing forces, a beta blocker should be started before (or concurrently with) it. The effects of nitroglycerin are not easily titratable, making it a less desirable drug for blood pressure control. Aspirin should be avoided, as it may increase bleeding complications. Morphine may be used for pain control and to decrease sympathetic tone. Imaging decisions surrounding aortic dissection are complex, incorporating such factors as patient safety (e.g. transport to imaging areas, administration of dye loads) and need for assessment of nonaortic structures (e.g. pericardial space) and functional anatomy (e.g. valvular regurgitation). As a general rule, MRI is not emergently available and lacks sufficient monitoring capabilities for a patient with suspected acute aortic dissection (MRI is useful for long-term, outpatient monitoring of dissection in most centers).

vii. Dressler’s syndrome is fever, pleuritis, leukocytosis, pericardial friction rub, and evidence of pericarditis or pleural effusion occurring several weeks after MI. It is thought to be autoimmune in nature and is treated with NSAIDs.

20. Cardiac tamponadea. JVD, decr. BP, muffeled heart sounds (Becks triad)

21. Cardiomegaly/CHF mgmt22. Weak after MI Dresslers syndrome23. Endocarditis-tripod, st-elevations24. PE –sharp inspiratory chest pain25. Metabolic

a. Hyperkalemia – give insulin, calcium to protect cardiac cells, MCC lab error due to cell damage when drawing bloodREPEAT

b. Hypokalemiac. Hypernatremia/Hyponatremia

26. Story doesn’t match picture Abuse27. Impetigo staph/strep28. IV fluids for fluid replacement for kid same as an adult NS or LR 20ml/kg bolus29. Febrile seizures work up30. Hip pain ddx

a. Leg-calf-Perthesb. Avascular necrosis of femoral headc. Slipped cap femoral epthasis

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31. Hand-foot-mouth diseasea. Coxsacchi B

32. Rash palms and solesa. Secondary syphilisb. Rocky mountain spotted feverc. Psoriasis

33. Upper Respiratory Obstructiona. Foreign bodyb. Epiglottisisc. Retropharyngeal abscessd. Angioedemae. Croupf. Pharyngitis

34. Periorbital cellulitisa. Pt looks really sickb. Cant move eye b/c of deep infection behind eye

35. Baker Acta. Can be done by any liscensed physician/policemanb. Hold for psych

36. Visual hallucinations = most likely due to a medical reason37. Auditory hallucinations = most likely due to psychitric reason38. Hysterical blindness

a. Somatic complaints but all psych39. Tension pneumo

a. Needle decomplression f/u chest tubeb. This patient needs emergent chest decompression and this is rapidly done by

needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime.

c. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin (answer B). The remaining answers are all correct statements regarding thoracentesis (answers C, D, E).

40. Nursemaids elbowa. Flex, supinate with thumb at radial headb. Feel pop

41. Unconscious patienta. SNOT (sugar, --,--, thyamine (from werkickies)

42. Intubate next step = check tube placement43. Trauma and blood at meatus retrograde urethrogram44. ABC’s Trauma45. FAST

a. If + and hypotensive laporotomy46. Gun shot wound and see bullet in belly laporotomy47. Chest trauma48. Flail chest49. Glascow Coma score50. Epidural vs subdural hematoma on CT51. Central cord syndrome

A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at the emergency department in a cervical collar and on a backboard. His only complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his arms against gravity and

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there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most appropriate management for this patient?A. Flexion and extention radiographs to rule out ligamentous injury

B. Discharge home with a hard cervical collar with neurosurgical follow-up

C. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness

D.

E. Immediate neurosurgical decompression

The answer is D. Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease. The ligamentum flavum buckles into the cord, resulting in a contusion of the cord’s central portion.

a.52. Burns

a. Parklands formulab. Rule of 9’sc. Give 4ml/kg/%body area burned

i. Half must be given in first 8 hrs53. Pain over snuff box FOOSH fx of scaphoid54. Lightning55. Near drowing

a. Salt vs fresh56. AMA/medical legal

a. Jahovas witnessb. Emergency for kids – tx w/o consent is ok

57. Physicin who last saw the pt is the one that is responsible for them when they are in transit

58. If person is AAOx3 and not Baker Acted and does not want a procedure – not allowed to do it

59. Confusion, wide based gait, and urinary incontinence = NPH60. Posterior circulation ischemia – stroke61. Double vision (not just double vision) = MAJOR problem

a. Mass or pituitary tumor62. Worst HA of life = subarachnoid hemorrhage63. Shingles at tip of nose worry abt herpes opthalgia64. Nervous system DZ

a. MSb. Guillan barretc. Myastenia gravis

65. Meningitis prophylaxis66. Transient loss of vision in one eye Amorosis fugax67. Seizure tx is benzo68. PE risk factors

a. Risk factors for PE include history of deep venous thrombosis (DVT), recent surgery or pregnancy, limb immobilization, confinement to bed, or underlying malignancy. Other risk factors include HTN, obesity, estrogen replacement therapy or oral contraceptives, autoimmune diseases, and cancer. Symptoms of PE include: dyspnea, pleuritic chest pain, apprehension, cough, hemoptysis,

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sweating, and syncope. The diagnosis is made: (1) if DVT is demonstrated by duplex US, venography, CT, MRI or some other technique; (2) if V/Q scan is convincingly positive; or (3) if pulmonary angiography, spiral CT, or another convincing test is positive.

b. CHR -S1 Q3 T3 pattern69. COPD/Asthma tx

a. Give Epi if dying70. Give O2 and CO2 goes up

a. CO2 narcosis71. Metabolic Acidosis

a. MUDPILES and Carbon Monoxide72. Tricyclic antidepressant OD

a. Anticholinergic sx, seizures73. Worry about OD’s with drugs that have long acting half lives

a. Same with long acting BP meds74. ASA/Acetaminophen OD’s75. Organophosphate OD76. Toxic ingestion77. OBGYN

a. Ectopic pregnancy (see in 5-8 weeks usually; not at 12)b. Bartholins abscessc. PID vsTuboovarian abscess vs Torsion – horrible pain USd. Toxic shock from tampon

Abdominal PainRegarding the diagnosis of acute appendicitis, all the following are true EXCEPT:

A. Rovsing’s sign is pain in the right lower quadrant upon palpation of the left lower quadrant.

B. The obturator sign is pain upon flexion and internal rotation of the hip.C. The psoas sign is pain upon extension of the hip.D. Rebound is usually elicited only after the appendix has ruptured or infarcted.

E. Vital signs are usually abnormal, even early in the course of acute appendicitis.The answer is E. The presentation of acute appendicitis varies tremendously. Early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. Other variations in presentation include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.

Rosving’s sign is described as:A. Pain that increases with the release of pressure of palpation.

B. Pain in the right lower quadrant when left lower quadrant is palpated.C. Tenderness in the right upper quadrant that is worse with inspiration.D. Pelvic pain upon flexion of the thigh while the patient is supine.E. Pelvic pain upon internal and external rotation of the thigh with the knee flexed.

The answer is B. Rosving’s sign is pain in the right lower quadrant when the left lower quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh rotation. All of these signs are associated with appendicitis. Murphy’s sign is cessation of inspiration during palpation of the right upper quadrant and is associated with acute cholecystitis.

In establishing a differential diagnosis of abdominal pain, which of the following is true?A. In patients with sickle cell anemia who present with abdominal pain and diarrhea,

shigellosis should be a top consideration.B. Radiation of pain to the scapula is suggestive of acute hepatitis.

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C. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.

D. Diverticulitis tends to cause pain in the right upper quadrant.E. Cervical motion tenderness is a useful physical finding for differentiating women

with or without acute appendicitis.The answer is C. Pain prior to nausea and vomiting is often suggestive of a surgical etiology of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.

Of the following pain patterns, which is the least likely associated with diagnosis of peptic ulcer disease?

A. relief of abdominal pain with antacidsB. pain that is worse preceding a mealC. unrelenting pain over a period of weeks

D. pain that awakens a patient in the middle of the nightE. non-radiating, burning epigastric pain

The answer is C. Pain from peptic ulcer disease typically occurs in periods of exacerbation and remission. Unrelenting pain over weeks or months should suggest an alternative diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some patients may also complain of chest or back pain. Pain is frequently severe enough to awaken patients from sleep in early morning hours but is often not present upon waking in the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.

A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she’s tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non-bilious, however it is projectile in nature. What is the most likely condition in this patient?

A. intussusceptionB. appendicitis

C. pyloric stenosisD. constipationE. viral gastroenteritis

The answer is C. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an “olive” palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults).

A 46 year old woman presents to the emergency department complaining of abrupt onset of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is pacing around the stretcher and appears extremely uncomfortable. She has never experienced this type of pain previously and denies fevers or other symptoms. Renal calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi in this patient?

A. Ultrasound is the study of choice for detecting small ureteral calculi.B. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.

C. Helical CT scan greater than 95% sensitive and specific for renal calculi.

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D. Urinalysis demonstrating hematuria confirms the diagnosis.E. KUB detects less than 10% of calculi.

The answer is C. Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study.

A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower quadrant pain associated with loose stools. He has had no fevers or bloody bowel movements. Similar symptoms in the past were self-limited. All vital signs lie within normal limits. Physical examination shows mild tenderness in the left lower quadrant, normal active bowel sounds and neither masses nor peritoneal signs. His primary-care physician can see him tomorrow in his clinic. What should be done next in the E.D.?

A. Admit for observation and serial examinationsB. Discharge home on high-fiber diet, laxatives and stool softenersC. Discharge home after a single dose of IV antibioticsD. Gastroenterology consult for endoscopy

The answer is B. This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.

You are treating a 25 year old male with the recent diagnosis of Crohn’s disease in the ED. Regarding Crohn’s disease, you know that:

A. Bleeding is common due to superficial bowel wall inflammationB. Lesions are typically contiguousC. There is a small increased risk of colon cancerD. Small bowel involvement is rare

The answer is C. Although Crohn’s disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as “skip lesions”) and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn’s such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.

A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is obtained. Which of the following is the most likely operative finding in this patient?[image]

A. Inflamed appendix

B. Rectus sheath hematomaC. Ruptured spleenD. Small bowel obstruction

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The answer is D. Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman’s history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology.

All of the following factors predispose to cecal volvulus EXCEPT:

A. severe chronic constipationB. marathon runningC. pregnancyD. age 25-35E. prior abdominal surgery

The answer is A. Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle.

A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient’s condition?[image]

A. Emergent percutaneous drainage in the emergency department is indicated.B. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and

ampicillin should be instituted immediately.C. Etiologic agents of this condition include bacteroides, E. coli, Klebsiella,

Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica.

D. Elevations of WBC, bilirubin, alkapine phosphatase and serum aminotransferases will be seen on laboratory studies.

E. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm.The answer is A. The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess.

Which of the following pairings of referred pain and causal disease is least likely to be encountered?

A. shoulder pain—ruptured spleenB. sacral pain—ovarian torsion

C. epigastric pain—myocardial infarctionD. inguinal pain—ureteral colicE. thoracic back pain—pancreatitis

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The answer is B. Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain.

A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient?

A. barium enema to evaluate for carcinoma of the colon

B. admission for intravenous antibiotics and fluidsC. type and cross two units of packed red blood cellsD. immediate surgical interventionE. discharge on oral pain medications

The answer is B. For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis.

CHEST PAIN

A 70 year old woman presents with chest pain that began 2 hours ago. She describes it as substernal radiating to her jaw and left shoulder; there is no other area of pain or radiation. She took an aspirin at home but the pain is not better. She also took 3 sublingual nitroglycerin tablets en route to the hospital. Her initial EKG shows ST elevation in the anterior leads >2mm and ST depression in the inferior leads. The nurse has already administered oxygen, placed her on an EKG monitor, and attained IV access. You order beta-blockade and nitroglycerin for pain relief, and the supervising resident asks you which of the following should be done next:

A. Call her primary care physician.B. Call cardiology to request a stat echocardiogram to check for wall motion

abnormalities and aortic dissection.C. Give her a GI cocktail to check for pain relief from this.

D. Send her to radiology for a good-quality chest X-ray.E. Call cardiology for a decision between thrombolytic and percutaneous coronary

intervention.The answer is E. This patient is having an acute myocardial infarction. AMI is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-

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inhibitor should also be administered – selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection.

A 72-year-old male presents with five hours of substernal chest pain and pressure despite taking three sublingual nitroglycerin. You order an EKG. What findings on the EKG would indicate that this patient is potentially a candidate for thrombolytic therapy?

A. ST-segment elevation of at least 1 mm in two or more contiguous leadsB. ST-segment depression of at least 2mm in any precordial leadC. Atrial fibrillation with a rapid ventricular responseD. Ventricular tachycardia

The answer is A. “Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm (1 small box) ST-segment elevation in two or more contiguous leads.”A 58-year-old male previously in good health presents with chest pain for two hours. Vital signs are BP 126/78, HR 80 (sinus rhythm), RR 14, oxygen saturation 99%, T 36.8. His EKG shows ST segment elevation in leads II, III, aVF and V1. ST-segment elevation is greater in lead III than in lead II. What additional diagnostic test is indicated prior to giving nitroglycerin?

A. CXR

B. d-dimerC. EKG with right-sided leadsD. Echocardiogram

The answer is C. “Nitrate-induced hypotension is also suggestive of right ventricular infarction, and of tamponade. Initial therapy for both would include volume loading and avoidance of vasodilators or other agents that may lower the blood pressure.”“ST segment elevation in lead V1 in the setting of inferior MI (i.e., ST segment elevation in leads II, III, and aVF rather than in the setting of concomitant ST segment elevation in all anterior precordial leads) is suggestive of right ventricular infarction.”“ST segment elevation is usually greater in lead III than in lead II when right ventricular infarction coexists with inferior AMI.”“Application of “right-sided” precordial leads is the best means to diagnose right ventricular infarction with the ECG. These leads, as a mirror image of the left precordial leads, demonstrate ST segment elevation with right ventricular infarction in leads V3R to V6R, with V4R having the highest sensitivity.”

A patient with nontraumatic chest pain is administered nitroglycerin in the field and has subsequent drop in blood pressure. An EKG reveals ST-segment elevation in lead V4R. What is the diagnosis?

A. right-ventricular MIB. unstable anginaC. anteroseptal MID. pericarditisE. pulmonary embolism

The answer is A. The ST-segment elevation in the right-sided lead V4R is strongly suggestive of right-ventricular MI.

A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent substernal chest pressure. A report from the patient’s primary care physician’s office states that

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an EKG performed four days ago was completely normal. Repeat EKG in the ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What intervention would be indicated to provide definitive management for the findings seen on EKG in this patient?

A. Continuous cardiac monitoring for 24-48 hoursB. Urgent placement of a cardiac pacemakerC. Radiofrequency ablation

D. Emergent revascularization with thrombolytics or percutaneous coronary intervention (PCI)The answer is B. “In the face of an AMI, the risks of complete heart block are much greater when new or preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic placement of a ventricular demand pacemaker is indicated.”

A 64 year old female presents to the emergency department with chief complaints of occipital headache and chest pain. Physical examination reveals a blood pressure of 200/118 as well as edema of the optic disk. Of the diagnoses below, the most likely is:

A. hypertensive urgencyB. moderate hypertensionC. white-coat hypertensionD. acute hypertensive (non-emergency/non-urgency) episode

E. hypertensive crisisThe answer is E. Elevated blood pressure in the setting of optic disk edema is a hallmark of malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While hypertensive urgency is not consistently defined in the medical literature, this patient's presentation indicates that there is some end-organ damage and thus the diagnosis is malignant hypertension. The "white-coat" syndrome, in which patients' blood pressures are elevated only in the clinical setting and not at home, has been shown to account for as many as a fifth of all cases of newly diagnosed "hypertension." Understanding of this phenomenom is important for emergency physicians, since its frequency explains why patients should not be given a diagnosis of new-onset hypertension based on E.D. measurements.

A 29-year-old male presents to the emergency department complaining of substernal chest pressure. The patient used cocaine and alcohol 3 hours prior to admission. On exam, the patient has a blood pressure of 160/100 mm Hg and heart rate of 150 beats per minute with ST-segment changes in the inferior leads on EKG. Which of the following is the best medication to treat the patient’s cardiovascular status?

A. LidocaineB. Lorazepam

C. MetoprololD. Phenoxybenzamine

The answer is B. In a patient with suspected myocardial ischemia secondary to cocaine abuse, beta blockade is probably contraindicated as it may lead to uncontrolled alpha-agonism and could cause worsening hypertension (this notion continues to be debated). Lidocaine is contraindicated and the use of nitroglycerin is controversial.

Trauma

An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture

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site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient?

A. No specific treatment requiredB. Immediate dental consult to avoid abscess formationC. Replace fractured piece and place acrylic splintD. Application of calcium hydroxide, placement of aluminum foil, and dental follow-

up

E. Placement of tooth fragment in saline gauze, outpatient dental follow-upThe answer is B. Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation.

Which is not part of the Ottawa ankle rules?A. inability to walk 4 steps at the time of the injuryB. inability to walk 4 steps in the emergency departmentC. tenderness over the lateral malleolusD. tenderness over the medial malleolus

E. tenderness over the talusThe correct answer is E. The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed.

In a patient with a suspected ruptured globe from penetrating trauma to the eye, all of the following should be performed EXCEPT:

A. ascertainment of tetanus statusB. ascertainment of intraocular pressure via tonometryC. ophthalmology consultationD. visual acuity assessmentE. administration of broad spectrum antibiotic therapy

The answer is B. Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury. Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical.

Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement. What is the most likely cause of his symptoms?

A. retrobulbar hematoma

B. orbital blow-out fractureC. hyphemaD. ruptured globeE. chemosis

The answer is A. Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause

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inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement. Yet, they do not present with proptosis – unless complicated by retrobulbar pathology.

Following a brawl at a local bar, a gentleman presents with an impressive right-sided periorbital ecchymosis. All of the following physical examination findings would suggest an orbital blowout fracture EXCEPT:

A. right-sided infraorbital subcutaneous emphysema

B. proptosisC. diplopia with upward gazeD. anesthesia of the right infraorbital regionE. right-sided epistaxis

The answer is B. Orbital blowout fractures classically involve the maxillary or ethmoid sinus and consequently often cause either epistaxis (through the connection of the maxillary sinus with the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral infraorbital region. If the inferior rectus muscle gets trapped within the fracture of the inferior orbital wall, patients will be unable to look upward causing diplopia with upward gaze. Orbital blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should prompt physicians to suspect the possibility of a retrobulbar hematoma.

A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street fight. At the scene, there is some bleeding, which is controlled with direct pressure. He presents to the emergency department breathing comfortably and in no distress. His pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a 1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea. There is mild oozing and no obvious underlying hematoma. There is no obvious subcutaneous air, and he has clear lung sounds. What is the most appropriate management for this patient?

A. CT scan of the neck and discharge home after 6 hours of observationB. Immediate operative explorationC. Local wound exploration and discharge home if no significant injury identifiedD. Local wound exploration and discharge home after 6-hour observation periodE. Angiography, esophogram, and admission for observation

The answer is E. Zone I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted.

Which of the following is an accurate statement?A. Bedside ultrasound can reliably determine the etiology of hemoperitoneum.

B. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum.C. Bedside ultrasound can image the retroperitoneum.D. Bedside ultrasound is the test of choice for diagnosing solid organ injury.E. Diagnostic peritoneal lavage usually cannot identify the presence of

hemoperitoneum.The answer is B. Diagnostic peritoneal lavage is extremely sensitive for the detection of hemoperitoneum and can lead to many negative laparotomies. Neither bedside ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury.

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A 36 year old man is a restrained driver involved in a high speed MVA where his car is struck on the driver’s side door with significant intrusion. His physical exam is significant for a large contusion on his left flank. His abdominal exam is benign and rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross hematuria. Which test is indicated to evaluate for the presence of urologic injury?

A. Ultrasound of the kidneysB. CT abdomen / pelvis with IV contrast aloneC. CT abdomen / pelvis with IV and transurethral contrastD. Ultrasound of the bladder

E. CT abdomen / pelvis without contrastThe answer is C.

In which of these patients is emergency department thoracotomy indicated?A. All of the above should undergo emergency department thoracotomy.B. Pedestrian struck with massive pelvic fractures who loses pulses and blood

pressure at the scene

C. Patient with stab wound to the anterior chest who is dyspneic with an oxygen saturation of 80% and a blood pressure of 168/102

D. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60

E. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being extricated, and arrives at the E.D. after a 45-minute transportThe answer is D. Emergency Department thoracotomy is a controversial procedure. When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt trauma has a dismal success rate and is generally not considered an indication for ED thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An awake patient with a relatively normal blood pressure does not need one performed in the Emergency Department. An unconscious and pulseless patient with a detectable blood pressure has the best chance for survival.

A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally. The entrance wound is just above the right breast and an exit wound is noted in the right axilla. What is the most appropriate management of this patient?

A. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to search for cardiac or pulmonary vascular injury

B. IV access, portable chest X-ray, right chest tube placement if X-ray shows a pneumo- or hemothorax, admission to the ICU for observation

C. IV access, endotracheal intubation, CT scan of chest to look for pneumo- or hemothorax, or injuries to the heart or great vessels

D. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac or pulmonary vascular injury

E. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stableAnswer is E

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Which is the most common associated neurological finding with a distal radius fracture?

A. Wrist dropB. Weakness of finger adductionC. Decreased sensation over the hypothenar eminanceD. Weakness with flexion at the finger MCP jointsE. Decreased sensation over the thenar eminance

The answer is E. This finding is due to median nerve injury.

An 82 year old woman with osteoporosis slips and falls onto her right hip. She cannot get up and is brought to the emergency department by ambulance. As you enter the room you notice her right leg is abducted and externally rotated. What type of injury does she most likely have?

A. Femoral neck fractureB. Posterior hip dislocationC. Subtrochanteric femur fractureD. Intertrochanteric femur fractureE. Acetabular fracture

The answer is A. Patients with dislocation tend to have internal (not external) rotation.

The answer is C. Blood in the sinuses can be a useful indirect indicator of facial fracture.

There are many species of bacteria in the human mouth, and Eikenella corrodens is an aggressive one, frequently causing infection in the first 24 hours after injury.

The overall evidence points to a superior-medial to inferior-lateral wound trajectory, with subcutaneous ecchymosis indicating the missile track and the more ragged wound at the inferior-lateral (groin) region most likely an exit wound. However, though wound description is very important for the emergency physician (both as a guide to injury evaluation and also as an early characterization of wounds, before interventions such as wound exploration obscure physical findings), speculation as to whether wounds are entrance or exit wounds are best left off of the E.D. record. Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus, the best course is a meticulous description (or photograph) of the wound, noting items such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to expansion of gun barrel gases in a contact wound) but leaving interpretation of the physical evidence to forensics experts. The wound characteristics are not consistent with self-inflicted injury, though the ED physician should have a low index of suspicion for psychiatric consultation when there is doubt on this subject.

A patient presents to the ED after a fall with chest pain. A chest xray shows a rib fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically stable trauma patient?

A. Heliox by face mask

B. 100% oxygenC. Chest tube placementD. Immediate needle decompression

The answer is B. An occult pneumothorax may resorb with only oxygen administration, not requiring invasive management. Needle decompression is used for tension pneumothorax, and heliox may be used for reactive airway disease to reduce resistance to flow.

You are practicing in a trauma center a receive a call from an outlying facility that they would like to transfer a male patient to you with a spinal cord injury after significant flexion and compression of the vertebral body. What does this injury pattern tell you about the patient’s symptoms?[image]

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Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving

A. Patients with anterior cord syndromes have only sensory symptomsB. The patient likely has symptoms on only one side of the his bodyC. The patient likely has paralysis and loss of sensation to pain and temperature

bilaterally below the lesionD. The patient likely disproportionately greater weakness in the lower extremities

(as compared to the upper extremities)The answer is C. Answer A describes central cord syndrome, typically caused by hyperextension. Answer C describes Brown-Sequard Syndrome, caused by hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to the anterior spinal artery; patient with this cord syndrome often have more than just sensory symptoms.

In differentiating high voltage electrical injury from lightning injury, which of the following is your best discriminator?

A. Loss of consciousnessB. Deep burnsC. Cardiac arrest

D. Fractures or dislocationsThe answer is B. Patients with high voltage injury commonly present with devastating burns. The burns are most severe at the source and ground contact points. The most common sites of contact with the source include the hands and the skull. The most common areas of ground contact are the heels. Deep burns occur in less than 5% of lightning injuries. Electrical injuries may cause four types of superficial burns or skin changes: linear burns, punctate burns, feathering, or thermal burns. Loss of consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage electrical injury and lightning injury. Electrolyte abnormalities are not common in either injury.

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