SAEM QUESTIONS AND ANSWERS GRADED A

SAEM QUESTIONS AND ANSWERS GRADED A subungual hematoma drane using 18 guage needle and discharge home Correct Answer: diagnosis and management etomidate (Cardioprotective) Correct Answer: induction agent of choice when decreased myocardial contractility is a concern etomidate Correct Answer: induction agent known to cause transient adrenal suppression, causing its use in septic patients to be controversial heel (sural nerve block) Correct Answer: portion of plantar aspect of foot not anesthetized by posterior tibial nerve block age (somewhere between 5-12, controversial) Correct Answer: only absolute contraindication to cricothyrotomy lightheadedness and diziness Correct Answer: first signs of lidocaine toxicity can place deep structures at risk Correct Answer: reason why vertical mattress sutures are not recommended for the palm fentanyl (reverse with naloxone, if not effective may need neuromuscular blockade and intubation) Correct Answer: analgesic which can cause respiratory depression, chest wall rigidity and glottic spasm mallampati Class 1 = full visualization of epiglottis Class 2: mostly full Class 3: barely visualized Class 4 = no visualization of epiglottis Correct Answer: scale which allows communication of ability to visualize structures of the posterior pharynx as a means of estimating intubation difficulty headache Correct Answer: most common complication of LP paronchyia digital block, surgical intervention (partiial removal of nail, and abx) Correct Answer: diagosis and management panic disorder Correct Answer: psychiatric disease with highest risk of suicide silent suicide Correct Answer: act of slowly killing oneself by nonviolent means, such as starvation or non compliance with essential medical treatment occult suicide Correct Answer: self destructive acts disguised as an accident C. elderly and caucasian Correct Answer: Suicidal risk is increased in this patient population: A. patients who have not been involuntarily committed b. patients who directly questioned about suicide c. elderly and caucasian D. patients taking lithium for bipolar disorder flexion and supination of elbow (imaging usually not needed if pain resolves after reduction) Correct Answer: management of radial head subluxation (nurse maids elbow) hill sachs deformity (compression fracture of the posterior lateral aspect of the humeral head) Correct Answer: most common fracture associated with shoulder dislocation asystole (followed by bradycardia) Correct Answer: most common rhythm seen in pediatric arrest 1. dry, warm, position, suction, stimulate 2. oxygen 3. ventilation 4. chest compressions 5. medications Correct Answer: order of operations for neonatal resuscitation maternal blood (ask about bleeding from nipples) Correct Answer: one possible cause of blood in vomit of a healthy appearing infant hypoxemia Correct Answer: most likely underlying cause of bradycardia in a newborn tube mm = (16 + age) /4 Correct Answer: equation for estimating endotrachael tube size 4 back blows If still obstructed 4 chest compressions If still obstructed jaw thrust, mouth inspected and removal of visual FB If still obstructed, mouth to mouth ventilation Repeat Correct Answer: management of choking infant under 1 year of age Childs nares childs little finger Body length broselow conversionn Age in years + 16 / 4 Correct Answer: 4 different methods for estimating pediatric endotracheal tube size hypovolemia Correct Answer: most common cause of shock in the pediatric population B. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function The answer is B. Early placement of a nasogastric tube to facilitate decompression of the stomach will help to prevent further impairment of ventilation. The rest are indications for endotrachael intubation in the pediatric trauma patient. Correct Answer: All of the following are generally accepted indications for endotracheal intubation of the pediatric trauma patient, EXCEPT: A. GCS score less than or equal 9, to secure airway and provide controlled hyperventilation B. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function C. any inability to ventilate by bag-valve-mask methods or the need for prolonged control of the airway D. respiratory failure from hypoxia or hypoventilation E. any trauma patient in decompensated shock and resistant to initial fluid resuscitation B. Salter II Correct Answer: A 7 year old boy falls off his bike onto his outstretched arm and sustains a supracondylar fracture. The fracture originates in the metaphysis and a portion of it extends into the physis (growth plate) without extending through to the epiphysis. How is this fracture classified? A. Salter I B. Salter II C. Salter III D. Salter IV E. Salter V SALTR type 1 - slipped - fracture plane passes through growth plate only type 2 - above - fracture passes through growth plate and metaphysis type 3 - lower - fracture plane passes through growth plate and epiphysis type 4 - through - fracture passes through eiphysis, growth plate and metaphysis type 5 - ruined - no fracture, but growth plate damaged from crush injury Correct Answer: Salter Harris Fracture CLasifcation The answer is C. Chest compressions should be started when an infant's heart rate is less than 60 bpm only if oxygen and adequate ventilation have first been tried and failed to increase the heart rate. The other choices are all correct regarding the use of chest compressions in the infant. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, page 105. Correct Answer: All of the following are true regarding chest compressions in the infant EXCEPT: A. Compressions should be performed at a rate of 90 per minute. B. Chest compressions should be accompanied by a ventilatory rate of 30 per minute. C. Chest compressions should be initiated whenever an infant's heart rate is less than 60 bpm. D. An appropriate position for performing chest compressions is to encircle the chest with both hands and place the thumbs side by side on the sternum. E. Correct depth of compressions is one-third the anteroposterior diameter of the chest. B Digoxin The answer is B. The drugs which may be given by endotracheal route can be remembered by the mnemonic "LEAN" — lidocaine, epinephrine, atropine, naloxone. Up to 10 times the IV dose diluted to 5mls and followed by 3-5 positive pressure breaths is necessary to achieve equivalent plasma concentrations. Digoxin must be given by the IV route. Correct Answer: In pediatric resuscitation the following drugs may be given by the endotracheal route, EXCEPT: A. atropine B. digoxin C. lidocaine D. epinephrine E. naloxone E. Hyperglycemia Due to low fat stores, inability to generate heat by shivering, and relatively large surface-to-volume area, the newborn infant is not easily able to maintain body temperature. Metabolic acidosis, increased oxygen consumption, hypoglycemia, and apnea are all physiologic consequences of hypothermia. Correct Answer: Low body temperatures in newborns can lead to severe physiologic consequences, which include all EXCEPT: A. increased oxygen consumption B. hypoglycemia C. apnea D. metabolic acidosis E. hyperglycemia A. maternal drugs The answer is A. Mucus, blood, meconium, the tongue, and pulmonary prematurity are the most frequent reasons for airway obstruction (and subsequent arrest) in the neonate. Maternal drugs can cause respiratory depression, not primary airway obstruction. Correct Answer: Which of the following is NOT a frequent cause of airway obstruction in the neonate? A. maternal drugs B. tongue C. meconium D. mucus E. blood C. 6mm' C. The correct endotracheal tube size can be approximated by using a simple formula: Inside diameter (ID) in mm = (16 + age in years) / 4. As this is an estimate, it is prudent to have the next smaller and larger size endotracheal tubes available as well. Estimation of tube size based on the size of the patient's fifth finger is less accurate. The tube size may also need to be modified based upon the etiology of the arrest (e.g. airway narrowing from infectious disease) Correct Answer: Approximately what inside diameter size endotracheal tube is appropriate for an 8 year old child? A. 10 mm B. 12 mm C. 6 mm D. 4 mm E. 8 mm E. TE fistula The answer is E. Patients with osteogenesis imperfecta have bony abnormalities (and possibly bluish sclera). Patients with significant congenital diaphragmatic hernia (CDH) have more dramatic presentations and are diagnosed in the perinatal period (if not earlier). Patients with mild CDH, or those with inborn errors of metabolism, could conceivably have a variety of presentations. The presentation in this case is most consistent with a tracheoesophageal fistula (TEF). In TEF patients, there is usually an associated esophageal atresia. Proximal esophageal atresia and distal TEF is the most common type of TEF. TEF occurs when the trachea and esophagus fail to separate properly prior to the 8th week. Correct Answer: A newborn presents to the emergency department a few days after hospital discharge. The infant has been noted to be drooling, choking, and coughing, and the mother reports seeing bubbles at the baby's mouth. Which is the most likely explanation? A. foreign body B. congenital diaphragmatic hernia C. osteogenesis imperfecta D. inborn error of metabolism E. tracheoesophageal fistula E. Back blow then chest thrust Controversy exists about the management of a choking child, but current guidelines rely on the back blow and chest thrust to clear an infant's airway. The Heimlich maneuver is discouraged due to potential injury to abdominal organs, and blind finger sweeps may push a foreign body further into the airway. Currently, for the choking infant less than a year, the following recommended sequence of treatment is: With the infant's torso positioned prone and head down along the rescuer's arm, four blows are delivered in the interscapular area. If the airway is still obstructed, the infant is repositioned supinely along the rescuer's arm and four chest thrusts (cardiac compressions) are delivered. The jaw thrust is used, mouth inspected, and foreign body removed if seen. If obstruction persists, mouth-to-mouth or mouth-to Correct Answer: Which of the following pairs of maneuvers are consistent with current recommendations for emergency care for a choking 5-month-old infant? A. chest thrust then Heimlich maneuver B. Heimlich maneuver then blind finger sweep C. Heimlich maneuver then chest thrust D. back blow then blind finger sweep E. back blow then chest thrust The answer is C. The pediatric airway is more anterior than the adult airway. The other choices (A, B, D, and E) are all correct regarding the pediatric airway as compared to that of the adult. Correct Answer: All of the following are true regarding the airway in children as compared to adults EXCEPT: A. Endotracheal intubation is usually performed using a straight blade in children. B. The infant's head is naturally in the correct "sniff" position, so a towel under the neck is usually unnecessary. C. The pediatric airway is more posterior than the adult airway. D. The pediatric tongue is relatively larger than the adult tongue. E. Teeth are more easily knocked out during a pediatric intubation than during that of an adult. B. Objects lodged in the proximal airway have the worst prognosis The answer is B. Large objects in upper airway and trachea have the worst prognosis and typically present with the most severe symptoms. Correct Answer: A 2 year old is brought in to the emergency department by his mother for difficulty breathing. The mother thinks he might have swallowed or aspirated something. In regards to this patient, which of the following is TRUE regarding foreign body aspiration or ingestion? A. The most difficult objects to remove are stiff, non-conformable objects B. Objects lodged in the proximal airway have the worst prognosis C. Large objects in the upper airway typically present with mild symptoms D. Small objects in the lower airways typically present with the most severe symptoms 140mg/kg Correct Answer: weight bosed dose of single ingestion of acetaminophen known to be toxic pyridoxine Correct Answer: antidote for isoniazid toxicity methylene blue Correct Answer: antidote for metheglobinemia C. Adult patient, nortriptyline ingestion (50 mg/tab x 100 tablets, 45 minutes PTA) Gastric lavage (GL) is generally not effective if performed more than a few hours (exact time ranges depend on clinical circumstances) after ingestion. Due to risks of lavage (aspiration, gastric/esophageal perforation), trivial ingestions are not an indication for GL. Due to the risk of aspiration with hydrocarbons and further injury with caustic ingestions, GL is contraindicated for hydrocarbon and caustic ingestions. Correct Answer: For which of the following cases (all of which are characterized by an ingestion history known with certainty) is gastric lavage most likely indicated? A. Adult patient, kerosene ingestion (8 oz, 20 minutes PTA) B. Adult patient, metoprolol ingestion (100 mg/tab x 100 tablets, 6 hours PTA) C. Adult patient, nortriptyline ingestion (50 mg/tab x 100 tablets, 45 minutes PTA) D. Adult patient, ibuprofen ingestion (800 mg/tab x 5 tabs, 20 minutes prior to arrival (PTA) in the ED D. opiods The answer is D. The hallmark signs and symptoms of clonidine toxicity include:hypotension, bradycardia, mental status change, respiratory depression, and miosis. The presentation very closely mimics opioid toxicity. Correct Answer: The clinical presentation of clonidine toxicity most closely mimics toxicity from which of the following classes of medication? A. Stimulants B. Beta blockers C. Cholinergics D. Opioids B Memory Loss The answer is B. Lead toxicity affects a variety of systems. The central nervous system effects are many and range from encephalopathy and seizure to sleep disturbance and memory deficits. The peripheral nervous system can also be involved, with paresthesias and wrist drop being common. Colicky abdominal pain is often present. While dermatitis is not common in lead poisoning, you can see bluish lead lines on the gingiva. Correct Answer: Severe lead toxicity can commonly result in which of the following clinical symptoms A. Stocking glove peripheral neuropathy B. Memory loss C. Dermatitis D. Constipation D Tachypnea The answer is D. Withdrawal syndromes tend to have symptoms that are the reverse of intoxication syndromes. In opiate withdrawal, individuals present with CNS excitation, diarrhea, mydriasis, tachypnea and often abdominal cramping and vomiting. While uncomfortable, opiate withdrawal is not life threatening and is managed symptomatically Correct Answer: During opiate withdrawal which of the following symptoms would you expect to find? A. Urinary retention B. Constipation C. Pruritis D. Tachypnea The answer is A. The patient is not intubated. The pathology in the right hemithorax appears as hyperdensity, rather than air density (not a pneumothorax), and involves more than the right upper lobe. Correct Answer: 1 A thin 18 year old female complains of acute onset of sharp right-sided chest pain this morning. She has developed some mild shortness of breath during the morning and thought she should get it checked out. Her chest X-ray is shown in the Figure. The next course of action should be: [image] photo courtesy of eM A. Chest tube placement B. Antibiotics C. Needle decompression D. Electrocardiogram