Amy Kaji MD PhD, faculty at Harbor-UCLA, has created an extraordinary set of Emergency Medicine review questions. These questions will live on WikEM with eventual incorporation into articles and CME modules. Please help format the questions for wiki quiz format.

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<quiz> {Shock question – Regarding shock, all of the following statements are TRUE, EXCEPT: |type="()"} -The first clinical manifestations of hemorrhage are tachycardia, then a slight increase in diastolic BP, causing the pulse pressure to narrow. -Septic shock causes three major effects that must be addressed during resuscitation: hypovolemia, cardiovascular depression, and induction of systemic inflammation. -Cardiogenic shock results when more than 40% of the myocardium becomes necrosed from ischemia, inflammation, toxins, or immune destruction. +For anaphylactic shock (with hypotension), epinephrine should not be used in the presence of coronary artery disease. ||Rosen, pp. 41-56. Epinephrine effectively counteracts the vasodepression, bronchoconstriction, fluid transudation, and reduced cardiac function in anaphylaxis. Epinephrine should be administered intravenously in patients with hypotension, even in the presence of coronary artery disease. Initially, 1ml of 1:10,000 (100 micrograms) can be injected slowly and the response monitored. -A pulmonary embolism large enough to cause shock results in pulmonary ventilation-perfusion mismatching, so arterial hypoxemia becomes a significant problem.

{Blood components question – Regarding blood components, which of the following statements is FALSE? |type="()"} +A male trauma patient who is exsanguinating should immediately receive O-negative blood. ||Rosen, pp.56-61. Universal donor group O is immediately available and is used when blood must be given at once to hemorrhaging, unstable patients. Women of childbearing age need group O-negative blood, and all others can receive group O-positive blood, which is more readily available. Type specific blood (ABO grouping and Rh type) is usually available in 5-10 minutes, whereas it usually takes 45 minutes to process fully cross-matched blood. -Platelets are indicated prophylactically when the count is less than 20,000 or less than 50,000 and there is a planned invasive procedure; spontaneous bleeding is common when platelets are less than 10,000. -A unit of FFP includes all clotting factors, including factors V and VIII, and it typically has a volume of 200 to 250 ml and must be ABO compatible. -Crossmatching is unnecessary for platelets, and on average, a single unit raises the platelet count by 5,000. -Transfusion-related acute lung injury (TRALI), which is indistinguishable from acute respiratory distress syndrome, results from transfusion of white cell antibodies that react with the recipient’s leukocytes.

{Pediatric resuscitation question – Regarding pediatric resuscitation, all of the following statements are TRUE, EXCEPT: |type="()"} -Any drug or fluid that can be given intravenously can also be given by the intraosseous route. -Rescue breaths are given at a rate of 30 breaths/minute in neonates, 20 breaths/min in infants and children, and 12 breaths/min in older children and adolescents. -Epinephrine is indicated in the following cardiac arrest settings: asystole, PEA, and VF. +The initial treatment of bradycardia with hypotension is atropine. ||Rosen, pp. 97-118. The initial treatment of bradycardia in any patient is ensuring adequate oxygenation, ventilation, and temperature. If bradycardia persists despite adequate oxygenation and ventilation and administration of epinephrine, administration of atropine may be appropriate. Atropine (0.02 mg/kg) is recommended in the treatment of symptomatic bradycardia caused by AV block or increased vagal tone (ET intubation). A minimum dose of 0.1 mg is used to avoid paradoxical bradycardia. Epinephrine is generally more effective in the treatment of bradycardia accompanied by poor perfusion and hypotension. -Asystole is the most common pediatric arrest rhythm, while bradycardia is the second most common pediatric arrest rhythm.

{Neonatal resuscitation question – Regarding neonatal resuscitation, which of the following statements is TRUE? |type="()"} -Bradycardia (heart rate < 100/min) is the major indicator of hypoxia. -The first resuscitation medication that should be used is 100% oxygen. -Epinephrine is indicated for asystole and heart rate less than 60/min despite effective ventilation with 100% oxygen and chest compressions. -To prevent complications caused by hypothermia, all newborns except infants with meconium present immediately should be dried off and placed under a radiant heat source. and warm blankets should be used. +All of the above ||Rosen, pp. 118-125. All of the statements are true! Most healthy newborns respond to the simple PALS measures of: dry, warm, position, suction, stimulate.

{Trauma question – Regarding trauma, which of the following statements is FALSE? |type="()"} -Trauma is the leading cause of death in those 1 to 37 years of age. -The priorities in the treatment of trauma patients are to secure the airway, maintain ventilation, control hemorrhage, treat shock, and stabilize the cervical spine. -Indications for active airway management include: airway obstruction, airway protection in the obtunded patient, and respiratory failure. -Cardiac contusion can produce ST segment elevations in the area of injury, T wave inversions, and bundle branch block. +Emergency thoracotomy may be indicated for blunt trauma victims without signs of life in the field. ||Rosen, pp.300-316. Blunt trauma victims with no signs of life in the field have no chance for survival and should not undergo an emergency thoracotomy. Blunt trauma patients who arrest in the emergency department and penetrating trauma patients with no signs of life in the field also have a dismal prognosis. Patients with penetrating trauma who arrest in transport or in the emergency department have the best prognosis and are most likely to benefit from emergency department thoracotomy.

{Trauma question – Regarding emergency thoracotomy, which of the following therapeutic measures may be taken after the chest is open? |type="()"} -After identifying the phrenic nerve, perform a pericardotomy to relieve tamponade. -Compressor cross-clamp the pulmonary hilum to control pulmonary hemorrhage. +Cross-clamp the ascending aorta to maximize splanchnic perfusion. -Perform open cardiac massage. -All of the above except C ||Rosen, pp. 300-316. The descending aorta is compressed and clamped to maximize cerebral and coronary perfusion.

{Thoracentesis question - The most frequent complication caused by inserting a thoracentesis needle into the thorax from either the anterior or posterior approach is: |type="()"} +the creation of a pneumothorax ||Robert and Hedges, p.145 (130-147) - While all of the listed complications can occur after a thoracentesis, pneumothorax is the most common. The risk for pneumothorax is greater in patients who are intubated on positive pressure ventilation, particularly in patients with a malignancy who are undergoing a therapeutic thoracentesis. Cough occurs in up to 9% of patients. While rare, unilateral pulmonary edema may occur after evacuation of pleural fluid. In addition to re-expansion hypotension, note that transient hypoxia may also occur from ventilation-perfusion mismatch. Finally, infection (2%), hemothorax and hemoperitoneum are potential complications, as well.

-cough

-unilateral pulmonary edema -reexpansion hypotension -hemothorax

{Tube thoracostomy question - Regarding chest tube thoracostomy, which of the following statements is FALSE: |type="()"} -As the collapsed lung expands, either air or fluid will follow the path of least resistance and enter a functioning drainage tube, regardless of the tube's location. -A tube directed posteriorly and toward the apex of the lung has proved to be satisfactory for drainage of either fluid or air. +An underlying bleeding dyscrasia is an absolute contraindication to chest tube thoracostomy. ||Roberts and Hedges, p.155 (148-172). While there are several relative contraindications (multiple adhesions and blebs, need for immediate open thoracotomy, bleeding dyscrasia, and recurrent pneumothorax mandating surgical treatment), there are no absolute contraindications in the compromised patient who requires the procedure. A tube directed posteriorly and toward the apex of the lung has proved to be satisfactory for drainage of either fluid or air, because as the collapsed lung expands, either air or fluid will follow the path of least resistance and enter a functioning drainage tube, regardless of the tube's location. -Empyema is an indication for chest tube placement. -Suction is recommended at least initially in all patients with chest tubes placed either for pneumothorax or hemothorax.

{Cricothyrotomy question - Regarding the performance of a cricothyrotomy, which of the following statements is FALSE: |type="()"} -The cricothyroid membrane is bounded by the thryoid cartilage superiorly and the cricoid cartilage inferiorly. -After the skin incision, a short stabbing incision about 1 cm long is made in the lower part of the cricothyroid membrane. -In an adult, a no. 5 (female) or 6 (male) Shiley tracheostomy tube is an appropriate size. -Age< 5 years is a relative contraindication to surgical cricothyrotomy. +All of the above statements are true. ||Roberts and Hedges, pp.57-74. In children, the cricoid is the narrowest part of the airway, and transtracheal ventilation may be preferred. Absolute contraindications are as follows: 1) endotracheal intubation can be accomplished easily and quickly and there are no contraindications to endotracheal intubation; 2) transection of the trachea with retraction of the distal end into the mediastinum; and 3) fractured larynx or significant damage to the cricoid cartilage or larynx.

{Trauma and pregnancy question – A 30 year old G2P1 32 weeks EGA was in a minor motor vehicle crash and sustains a laceration and has no abdominal tenderness to palpation although she did “bump” her lower abdomen. She has a normal exam other than having a gravid, nontender uterus, as well as a small 3cm laceration on her forearm with no neurovascular deficits. She is Rh negative. In managing this patient, which of the following statements is FALSE? |type="()"} -The patient should have 4 hours of cardiotocographic monitoring. -The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 3 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. -Tetanus toxoid should be administered to the patient if she has not been vaccinated in the last 10 years. +A 50 microgram dose of Rh immune globulin (RhIG) should be administered. ||Rosen, 316-327. All Rh-negative mothers who have a history of abdominal trauma should receive a prophylactic dose of RhIG. In the first trimester, the 50 microgram dose is used because the total fetal blood volume is only 4.2 ml by 12 weeks. During the second and third trimesters, 300 micrograms of RhIG is given, which protects against 30 ml of fetal-maternal hemorrhage. Minor trauma does not exempt the fetus from significant injury as 1-3% of all minor trauma result in fetal loss from placental abruption, and four hours of cardiotocographic monitoring is recommended. The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 3 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. Tetanus toxoid and immune globulin have no detrimental effect on the fetus. Proper immunization of pregnant women decreases the incidence of neonatal tetanus, since the tetanus antibody crosses the placenta. -The most common obstetric problem that is likely to occur in this patient is uterine contractions.

{Trauma and Brain Injury question - A colleague signs over (as a “pick-up”) care of patient who has sustained an intracranial hemorrhage after a severe motor vehicle crash in “sign-out” rounds. Which of the following is not an important management priority? |type="()"} -Preventing hypotension -Preventing hypoxia -Treating anemia +Inducing hypocarbia ||Rosen, p. 353(349-382) A primary goal in the emergency care of the head-injured patient is to prevent the systemic conditions that are known to worsen outcome after traumatic brain injury. The most common secondary systemic insults include hypotension, hypoxia, and anemia. Systemic hypotension (SBP <90) reduces cerebral perfusion, thereby exacerbating ischemia and infarction. The presence of hypotension nearly doubles the mortality from head injury. When hypoxia (PaO2 <60) is documented, the overall mortality from severe head injury also doubles. Anemia (Hct <30%) caused by blood loss can be detrimental to the head trauma patient by reducing the oxygen-carrying capacity of the blood, thus reducing the amount of necessary substrate delivered to the injured brain tissue. Other potential reversible causes of secondary injury in head trauma include hypercarbia, hyperthermia, coagulopathy, and seizures. Hyperventilation to produce an arterial PCO2 of 30-35 temporarily reduces ICP, and the onset of action is within 30 seconds, peaking at 8 minutes after the PCO2 drops to the desired range. The PCO2 should not be lowered to less than 25 mm, since this can cause profound vasoconstriction and ischemia in normal tissues as well as injured areas of the brain. Hyperventilation is recommended for brief periods during the acute resuscitation and only in patients demonstrating neurologic deterioration. -Preventing hypercarbia, hyperthermia, coagulopathy, and seizures.

{Trauma and pregnancy question – After MINOR abdominal trauma ina viable (> 24 weeks) pregnancy, fetal outcome is best predicted by which of the following? |type="()"} -Maternal vital signs -Abdominal tenderness -Serum D-dimer level -Ultrasound +Cardiotocographic monitoring || Rosen, p. 319. Only cardiotocographic monitoring for a minimum of 4 hours is useful to predict fetal outcome for women with less severe trauma.

{Trauma and pregnancy question – The most sensitive indicator of placental abruption is: |type="()"} -vaginal bleeding +fetal distress ||Rosen, p. 319. Classical clinical findings of abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, maternal hypovolemia or a change in the fetal heart rate. The most sensitive indicator of placental abruption is fetal distress. There is a close linkage of abruption to uterine activity. Ultrasound is less than 50% accurate in detecting abruption. If the abruption bleeds externally or the placenta is positioned posteriorly, not enough blood collects to be seen sonographically. Note that 50-70% of fetal losses result from placental abruption. -uterine tenderness -abdominal cramps -ultrasound findings consistent with abruption

{You are performing a saphenous vein cut-down in the thigh, after several colleagues have failed at peripheral and central access in a patient with a severe GI bleed. You have chosen this site, as you know that the accessibility and large diameter of the greater saphenous vein in the thigh is a good option in the treatment of profound hypovolemia. Which of the following statements is FALSE? |type="()"} -The saphenous vein begins on the medial aspect of the knee and crosses anterolaterally as it ascends towards the femoral triangle and enters the fossa ovalis and joins the femoral vein. -Three to four centimeters distal to the inguinal ligament, the saphenous vein is of large caliber. -Typically, a skin incision is made perpendicular to the course of the vein. +After a self-retaining retractor is used to provide a wider field and the vein is isolated from the adjacent tissue and mobilized for 1 to 3 cm, proximal and distal ties are passed under the vein. The proximal suture is tied first and the distal tie is left untied at this point. ||(Roberts and Hedges, Chapter 22 Venous cutdown) - If proximal and distal tie ligatures are passed under the vein prior to cannulation, the distal ligature may or may not be tied after initial placement. If the distal ligature is tied, it should not be cut because the proximal tie is useful in controlling the vein. The proximal tie is not tied at this point but traction on it will control back-bleeding. Once the catheter is advanced into the lumen, and the cannula is connected to the IV tubing, the proximal ligature is tied around the vessel wall and the intraluminal cannula. -Using a hemostat, the vessel is elevated and the vein is stretched flat, and a pair of iris scissors or a No. 11 blade may be used to incise the vessel.

{Musculoskeletal question: Regarding anterior shoulder dislocations, which of the following is FALSE? |type="()"} -Anterior shoulder dislocatios are the most common major joint dislocation encountered in the ED. +It is important to assess the status of the radial nerve, since this is the most common nerve lesion found in anterior dislocations. ||Roberts and Hedges, p. 820 (Chapter 52) - The axillary nerve is the most common nerve lesion found in anterior shoulder dislocations. The sensory component is assessed by testing for sensation over the lateral aspect of the humerus, and the motor component is tested by assessing the strength of the deltoid muscle (which is difficult to do in the patient with a dislocated shoulder). Though rare, injuries to the ulnar and radial nerve may occur, and thus the neurologic assessment sould include a complete assessment of all major nerves to the arm. The presence of a neurologic deficit does not preclude closed reduction. Injury to the axillary artery is rare, usually occuring in the elderly, and can be quickly assessed by palpation of the radial pulse. -Reduction techniques include the Stimson maneuver, which has the advantage of not requiring an assistant. -The external rotation reduction method employs slow, gentle traction on the fully ADducted arm. -The scapular manipulation technique may be carried out as follows: 1) place traction on the affected arm as it is held in 90 degrees of forward flexion, with or withour flexion of the elbow 90 degrees (patient may be in the prone, supine, or seated); 2) stabilizing the superior aspect of the scapula with one hand and pushing the inferior tip of the scapula medially towards the spine.

{Musculoskeletal question: An 84 year old woman is brought in by paramedics after she sustained a trip and fall in her bathroom onto her left hip. Regarding her management, which of the following is FALSE? |type="()"} -You should provide her with adequate pain control with morphine or an alternative agent. -You should assess the neurovascular status of her lower extremity. +If her radiographs do not demonstrate a fracture, she should be discharged home, even if she is still unable to bear weight. ||Rosen, p. 746. If radiographs do not demonstrate a fracture, the patient must be observed while ambulating, since the inability to ambulate raises suspicion of an occult fracture. 5% of all hip fractures are radiographically occult on plain films. Failure to detect these injuries results in increased mortality, increased risk of subsequent displacement of the fracture, and a higher incidence of avascular necrosis. Thus, an MRI should be obtained, as it reveals a fracture that is imperceptible at the time of injury with 100% accuracy. A bone scan may also be performed, but its sensitivity is limited in the immediate injury period. The scan must be delayed 72 hours after the injury to achieve adequate sensitivity. -You should consider assessing the home situation for elder abuse. -You should confirm whether or not this was a mechanical fall or a fall precipitated by some other event (e.g., angina, TIA, sepsis, etc.).

{Trauma question: You are seeing a patient who has an extensive scalp laceration involving the galea, as a result of a car accident. Regarding management of this patient, which of the following is FALSE? |type="()"} -Methods for achieving hemostasis include the following: digital compression of the bleeding vessel, infiltration of wound edges with lidocaine w/epinephrine, ligation of bleeding vessel, pulling up the galea with a clamp and folding its edges to tamponade the bleeding vessels. -It is important to visualize the base of the laceration since it is easy to confuse a disruption in the galea or a tear in the periosteum with a skull fracture. -Irrigate the wound copiously and be mindful that contaminated or infected scalp wounds have the potential to cause serious scalp wounds. +You discover a large galeal laceration, and staples are the best method of closure. ||Rosen, p. 373. Disruption of the galea results in gaping scalp lacerations. Large lacerations of the galea must be closed to prevent the edges of the sound from pulling apart as the muscles within the galea contract. The galea, skin, and dermis can usually be repaired in a single layer with interrupted or vertical mattress sutures of 3-0 nylon or polypropylene. In scalp lacerations in which the galea is not involved, staples may be used in the repair. Because of the rich blood supply of the scalp, even very large scalp avulsions can survive. If the avulsion flap remains attached to the rest of the scalp by a tissue bridge, it should be reattached to the surrounding tissue. The base of the laceration should be well visualized, since disruption of the galea can be confused with skull fracture. Methods for achieving hemostasis include the following: digital compression of the bleeding vessel, infiltration of wound edges with lidocaine w/epinephrine, ligation of bleeding vessel, pulling up the galea with a clamp and folding its edges over the lacerated skin edges to tamponade the bleeding vessels. Irrigate the wound copiously and be mindful that contaminated or infected scalp wounds have the potential to cause serious scalp wounds, because the emissary vessels of the subgaleal layer drain directly into the diploe veins of the skull, which in turn drain into the venous sinuses. -Since the avulsion flap remains attached to the rest of the scalp by a tissue bridge, it should be reattached to the surrounding tissue.

{ENT question -You see a 22 year old male with a history of fever, absence of cough, swollen, anterior cervical nodes, and tonsillar exudate. Regarding management, which of the following is the most appropriate, according to the CDC? |type="()"} +Treat empirically for group A beta-hemolytic streptococcus (GABHS) with penicillin. ||Rosen, p. 277. Your patient has a Centor score of 4, and laboratory data may not be perceived to be cost effective. The CDC guidelines recommend for adults (patients greater than 15 years of age), the following: patients with viral symptoms – do not test or treat patients with symptoms of GABHS – use Centor criteria (history of fever, absence of cough, swollen, tender anterior cervical nodes, and tonsillar exudates). Centor score = 4 – perform RADT or treat presumptively Centor score = 3 – perform RADT or treat presumptively Centor score = 2 – perform RADT or do not test or treat Centor score = 1 or 0 – do not test or treat In all cases in which an RADT is performed, only those with positive results should be treated. Cultures should not be performed after a negative RADT, and the recommended antibiotic is penicillin. -Perform a rapid antigen detection test (RADT), and if negative, still treat presumptively since your suspicion is high. -Perform a RADT, and if positive, culture but don’t treat since your suspicion is low. -Perform a RADT, and since negative, culture. -None of the above is correct.

{Pregnancy question – The leading cause of death in pregnancy is: |type="()"} -appendicitis -trauma -placental abruption +thromboembolic disease ||Rosen, p.2756. Thromboembolic disease accounts for almost 20% of obstetric mortality, making it the leading cause of death in pregnancy. The risk of venous thrombosis increases during pregnancy to five to six times that of nonpregnant women. The risk is increased throughout pregnancy but is highest during the puerperium. Women who smoke, have varicose veins, or have a prior veneous thrombosis, as well as those who deliver prematurely or have postpartum hemorrhage are at higher risk. -ectopic pregnancy

{Pregnancy question – A 30 year old G1P0 EGA 10 weeks pregnant patient presents with vaginal spotting. She has a closed os and an IUP with good cardiac acitivy, confirmed by ultrasound. She asks you how common it is for clinically pregnant women to experience some bleeding, and what percent of women who bleed during early pregnancy miscarry. To respond correctly, you should state that: |type="()"} +About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry. ||Rosen, p.2740. About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry. The overall embryonic and fetal loss rate after implantation ranges up to one third of detectable pregnancies. The risk of miscarriage rises with increasing maternal and paternal age, tobacco and alcohol use, increased parity and history of vaginal bleeding; whereas the risk is only about 12% in females younger than 20 years old, it rises to about 30% in those older than 40 years of age. About 80% of miscarriages occur during the first trimester. Those with a history of bleeding who do not miscarry have otherwise fairly normal pregnancies, although they have about twice the risk of premature birth and low-weight infants. -Less than 10% of clinically pregnant patients experience some bleeding, and approximately 5% of all women who have bleeding during early pregnancy miscarry. -80% of clinically pregnant patients experience some bleeding, and approximately 75% of all women who have bleeding during early pregnancy miscarry. -90% of clinically pregnant patients experience some bleeding, and approximately 20% of all women who have bleeding during early pregnancy miscarry. -75% of clinically pregnant patients experience some bleeding, and approximately 90% of all women who have bleeding during early pregnancy miscarry.

{Pediatric airway question – Regarding viral croup, which of the following is FALSE? |type="()"} -Croup or laryngotracheobronchitis is the most common cause of upper airway obstruction in childhood, with a peak incidence at 2 years (range 6 months to 6 years) and most commonly occurs in the late fall, early winter, and spring. -Parainfluenza type 1 accounts for about half the cases, with Parainfluenza types 2 and 3, respiratory syncytial virus, influenza A and B, and rhinovirus, accounting for the remainder. -Classic clinical symptoms include a barky cough, hoarse voice, and high-pitched inspiratory stridor. -Scoring systems to assess the severity of croup include an evaluation of five signs: worsening stridor, retractions, cyanosis, heart rate, and respiratory rate. +The only evidence-based therapy available for treatment is the administration of cool mist. ||Rosen, p. 2526. The mainstays of treatment of mild, moderate, and severe croup are cool mist, aerosolized epinephrine, and glucocorticoids. A randomized trial of cool mist in moderate croup showed no clear benefit in improving oxygen saturation, respiratory rate, or assessment times. Either racemic or l forms of epinephrine may be used, as this acts on the alpha-adrenergic receptors in the subglottic mucosa. Epinephrine vasoconstricts and reverse edema and relieves acute symptoms in a subset of patients. In meta-analyses, oral and intramuscular (oral has equal efficacy, as long as the patient can tolerate the oral form) steroids have been demonstrated to decrease the rate of intubation, and facilitate improvement times, and are thus recommended for the management of croup. The effective dose is as low as 0.15 mg/kg.

{Environmental emergencies question – Regarding black widow and brown recluse spider envenomations, which of the following is FALSE? |type="()"} -Black widow spiders (BWS) are found in the temperate regions of six continents and are widespread through North America, including the western United States (California included). -Signs and symptoms associated with BWS (e.g. diffuse pain, muscle cramps, tachycardia, and hypertension) usually develop begin within 30 to 120 minutes of the envenomation. -After antivenom for BWS is administered, symptoms typically resolve within 30 minutes, with complete relief within 2 hours. +Brown recluse spider (BRS) envenomation is most common in west coast states, such as California. ||Harwood-Nuss – 1734-1739. Although BWS occur in Southern California, BRS are most common in the southern Midwestern states (but not California). Note that BRS have more local toxicity with eschar formation and necrosis, and these should not be debrided or excised. BRS may result in hemolysis and rhabdomyolysis. There is no antivenom available for BRS in the US, but there is one for BWS, which manifest severe life-threatening systemic signs. -Most bites from BRS have a benign clinical course, but necrosis with induration and eschar formation may occur, and systemic effects, such as fever, chills, headache, malaise, arthralgia, and myalgias progress after more than 24 to 48 hours and resolve by 72 to 96 hours postbite.

{Trauma/Burn question – Criteria for transfer of a burn patient to a burn center include all of the following EXCEPT: |type="()"} -Second degree burns greater than 10% of total body surface area (TBSA) -Burns that involve the face, hands, genitalia, perineum, and major joints +Age < 10 ||Harwood-Nuss - p.1107. All except age <10 are criteria for transfer to a burn center. In addition, other transfer criteria include: inhalation injury, any burn with concomitant trauma in which the burn injuries pose the greatest risk to the patient, and patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. -Chemical burns -Electrical burns, including lightning injuries

{Trauma question – Regarding replantation, which of the following is FALSE? |type="()"} -The amputated part should be wrapped in saline moistened gauze and placed in a sealed plastic bag or container, which is then placed in a water and ice bath. -An amputated part can survive 6 hours of warm ischemia and 12 hours of cold ischemia. +Indications for reimplantation include single digits proximal to the flexor digitorum superficialis insertion. ||Harwood-Nuss – p.1108. Single finger replantation proximal to the insertion of the flexor digitorum superficialis (mid portion of the middle phalanx) is not performed because of poor functional outcomes. These patients have almost no return of flexion. In contrast, replantation of amputations at the level of the distal interphalangeal joints usually results in a good functional outcome. Multiple finger amputations are usually considered for replantation. Replantation of the thumb is even considered when function of the replanted thumb is potentially limited because even a nonfunctional thumb is important for opposition. -Contraindications to reimplantation include crushed or mangled parts and multiple level amputations. -Replantation of the thumb is considered even when the function of the replanted thumb is potentially limited.

{Pediatric orthopedics question - A three year old is brought in by her parents because she has not used her left arm for a day. Which of the following statements regarding “nursemaid’s elbow” is FALSE? |type="()"} +Children with nursemaid’s elbow typically have swelling and warmth around the affected elbow. ||It is important to note that patients with nursemaid’s elbow do not have swelling, warmth, or ecchymosis about the elbow. If these findings are present, nursemaid’s elbow is unlikely to be the cause. -It is caused by distraction of the radiocapitellar joint in pronation followed by the upward slip of the annular ligament upon the radial head. -The most common mechanism of injury is that of axial traction on the extended arm usually occurring when an adult pulls up or swings a child by the arm. -Children with nursemaid’s will be noted to hold their arm at their side with the forearm in a pronated position. -There are two different methods commonly used for reducing a nursemaid’s elbow: hyperpronation and the supination/flexion technique.

{Toxicology question – Regarding digitalis intoxication, which of the following statements is FALSE? |type="()"} -The symptoms and signs of digitalis intoxication are nonspecific, but the most common symptoms reported in 80% of cases are nausea, anorexia, fatigue, and visual disturbance. -Chronic poisoning has an insidious onset and is accompanied by a higher mortality rate. +Orogastric lavage is the treatment of choice for an acute overdose. ||Rosen 2368-2373. There is no evidence to support gastric emptying for the treatment of digoxin overdose. There are at least 3 approaches to calculating Digibind dosages. The first is empiric. If a patient has a history of digitalis ingestion, consistent symptoms, and life-threatening dysrhythmias, then 10 vials may be administered over 30 minutes for acute ingestions and 4-6 vials for the average chronic ingestion. In patients in cardiac arrest, 20 vials may be administered by intravenous bolus. The second approach is used when the ingested dose is known, since one vial of Digibind contains 38mg of Fab fragments, which bind 0.5mg of digoxin or digitoxin. A third approach is to base the dosage on the steady-state serum digoxin or digitoxin level after 6 to 8 hours. Dose (in number of vials) = (serum dig level X weight in kg) / 1000 -The median time to initial response to Fab fragment therapy is 19 minutes after completion of the Fab infusion, but complete resolution of digitalis-toxic rhythms may require hours. -One approach to calculate the digibind dosage when the ingested dose is known is that one vial binds 0.5 mg of digoxin or digitoxin.

{Toxicology question – Regarding PCP intoxication, which of the following statements is FALSE? |type="()"} +For severe intoxication, manifested by altered mental status and violent, agitated behavior, the treatment of choice is hemodialysis or hemoperfusion. ||Rosen 2891-2893. Neither hemodialysis not hemoperfusion is indicated owing to the large volume of distribution and significant protein binding. Because there is no specific antidote for PCP, treatment is supportive. -Patients are frequently hypertensive and mildly tachycardic and demonstrate a mixure of cholinergic, anticholinergic, and adrenergic signs. -The eyes provide important clues to PCP intoxication, and horizontal nystagmus is extremely common. However, vertical, rotatory, or mixed nystagmus may occur. -Delusions of invulnerability have led to deaths during PCP intoxication. -Rhabdomyolysis occurs due to profound voluntary exertion, fighting against restraints, and mycolonic or dystonic muscle contractions.

{Toxicology question – The cardinal features of neuroleptic malignant syndrome (NMS) include all EXCEPT: |type="()"} -altered mental status -hyperthermia -muscle rigidity +vertical nystagmus ||Rosen 2445-2449. Most patients with NMS develop the cardinal features of altered mental status, muscle rigidity, autonomic nervous system instability, and hyperthermia within 3 days. The signs of NMS may develop gradually, however, and in any order. Physicians should consider discontinuing antipsychotic drugs in a patient who has developed one or more of the major manifestations of NMS. Most episodes resolve within 2 weeks after cessation of the offending medication, but some cases have lasted 6 months. -autonomic nervous system instability

{Toxicology question – Regarding isopropyl alcohol intoxication, all of the following would be expected EXCEPT: |type="()"} -gastrointestinal and CNS complaints -intoxicated behavior with the odor of acetone rather than ethanol on the breath +anion gap acidosis ||Rosen 2402-2405. Clinically, GI and CNS complaints predominate with isopropyl alcohol intoxication, and this may be suspected based on apparent inebriation with the odor of acetone rather than ethanol on the breath. Hypotension, although rare, signifies severe poisoning with a mortality rate of 45%. Hypothermia is frequent. Metabolic acidosis is NOT present with isopropyl alcohol intoxication unless accompanied by hypotension, gastrointestinal bleeding, or coingestants; this is a distinguishing feature. The most common laboratory abnormality is ketosis with little or no acidosis and normal blood glucose levels. The ketosis is from the metabolite acetone which can be detected in the blood 15 minutes after ingestion and in the urine 3 hours after ingestion. Isopropanolol and acetone contribute to the increased osmolar gap. Note that an osmolar gap > 50 mOsM/L is virtually diagnostic of a toxic alcohol ingestion. Hyperglycemia may be noted. In contrast to ethylene glycol and methanol, ADH blockade with ethanol and fomepizole is not indicated. Hypotension should be managed with fluids and pressors. If the patient remains hypotensive or has further vital sign deterioration despite these measures, dialysis is indicated. Some authors also recommend dialysis for isopropanolol serum levels > 400 mg/dL. -an elevated osmolar gap -hyperglycemia

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	TT is the 3rd most common cause of a malpractice lawsuit in adolescent males 12-17 years old.
	In the hands of an experienced emergency physician, it is possible to consistently and accurately differentiate TT from epididymoorchitis (EO) by physical examination alone.
	The presence of a cremasteric reflex essentially rules out TT.
	TT that present after 6 hours are not salvageable and no longer need to be evaluated in an emergent manner.
	Color Doppler ultrasound is a consistently reliable tool for confirming the diagnosis of testicular torsion.

	It is rapidly active, and it typically produces intubating conditions within 60 seconds of rapid intravenous bolus administration.
	Its clinical duration of action is 6 to 10 minutes, and full recovery of normal neuromuscular function occurs within 15 minutes.
	It is a negative chronotrope in children less than 10 years of age, and sinus bradycardia may ensue after administration.
	Succinylcholine remains the agent of choice for RSI in acute burn, trauma, stroke, spinal cord injury, and intra-abdominal sepsis patients if intubation occurs less than 5 days after the onset of the condition.
	It binds competitively to Ach receptors, preventing access to Ach and preventing muscular activity.

	Acute respiratory failure can be defined by the presence of at least two of four criteria: 1) acute dyspnea, 2) PaO2<50mm at room air, 3) PaCO2>50mm, and 4) significant respiratory acidemia.
	One potential adverse effect of positive-pressure ventilation includes decreased venous return to the heart and decreased cardiac output.
	The best approach to use in patients with asthma is to use small tidal volumes (5-8ml/kg) and high inspiratory flow rates to reduce inspiratory time and peak airway pressures.
	When inadequate expiratory time is allowed in the COPD patient, air trapping is exacerbated with each inspiration and may eventually result in a high level of intrinsic PEEP (iPEEP or auto-PEEP) such that the inhaled volume cannot overcome the exhaled volume; the solution is to build adequate expiratory time into the ventilator settings.
	The ventilator rate for COPD patients should be titrated as high as possible with I/E ratios of 1:1.

Kaji Review Questions (Main)

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