Kaji Review Questions (Main)

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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Set 1 || Set 2 || Set 3 || Set 4 || Set 5 || Set 6 || Set 7 || Set 8 || Set 9

1 How many minutes of apnea can a normal, healthy adult tolerate before oxygen desaturation to less than 90% occurs after administration of 100% oxygen for 3 minutes of normal, tidal volume breathing (preoxygenation)?

	1 minute
	3 minutes
	5 minutes
	8 minutes
	10 minutes

2 Regarding testicular torsion (TT), which of the following statements is true

	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.

3 If time is insufficient for a full 3 minute preoxygenation phase, how many vital capacity breaths using high-flow oxygen can achieve oxygen saturations and apnea times that match or exceed those obtained with traditional preoxygenation?

	3
	5
	6
	8
	10

1 Airway question – All of the following statements are TRUE about succinylcholine EXCEPT:

	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.

2 Ventilatory management question - Regarding mechanical ventilation, all of the following statements are TRUE, EXCEPT:

	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.

Point added for a correct answer:
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1 Shock question – Regarding shock, all of the following statements are TRUE, EXCEPT:

	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.
	A pulmonary embolism large enough to cause shock results in pulmonary ventilation-perfusion mismatching, so arterial hypoxemia becomes a significant problem.

2 Blood components question – Regarding blood components, which of the following statements is FALSE?

	A male trauma patient who is exsanguinating should immediately receive O-negative 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.

3 Pediatric resuscitation question – Regarding pediatric resuscitation, all of the following statements are TRUE, EXCEPT:

	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.
	Asystole is the most common pediatric arrest rhythm, while bradycardia is the second most common pediatric arrest rhythm.

4 Neonatal resuscitation question – Regarding neonatal resuscitation, which of the following statements is TRUE?

	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

5 Trauma question – Regarding trauma, which of the following statements is FALSE?

	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.

6 Trauma question – Regarding emergency thoracotomy, which of the following therapeutic measures may be taken after the chest is open?

	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

7 Thoracentesis question - The most frequent complication caused by inserting a thoracentesis needle into the thorax from either the anterior or posterior approach is:

	the creation of a pneumothorax
	unilateral pulmonary edema
	reexpansion hypotension
	hemothorax

8 Tube thoracostomy question - Regarding chest tube thoracostomy, which of the following statements is FALSE:

	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.
	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.

9 Cricothyrotomy question - Regarding the performance of a cricothyrotomy, which of the following statements is FALSE:

	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.

10 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?

	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.
	The most common obstetric problem that is likely to occur in this patient is uterine contractions.

11 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?

	Preventing hypotension
	Preventing hypoxia
	Treating anemia
	Inducing hypocarbia
	Preventing hypercarbia, hyperthermia, coagulopathy, and seizures.

12 Trauma and pregnancy question – After MINOR abdominal trauma ina viable (> 24 weeks) pregnancy, fetal outcome is best predicted by which of the following?

	Maternal vital signs
	Abdominal tenderness
	Serum D-dimer level
	Ultrasound
	Cardiotocographic monitoring

13 Trauma and pregnancy question – The most sensitive indicator of placental abruption is:

	vaginal bleeding
	fetal distress
	uterine tenderness
	abdominal cramps
	ultrasound findings consistent with abruption

14 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?

	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.
	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.

15 Musculoskeletal question: Regarding anterior shoulder dislocations, which of the following is FALSE?

	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.
	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.

16 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?

	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.
	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.).

17 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?

	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.
	Since the avulsion flap remains attached to the rest of the scalp by a tissue bridge, it should be reattached to the surrounding tissue.

18 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?

	Treat empirically for group A beta-hemolytic streptococcus (GABHS) with 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.

19 Pregnancy question – The leading cause of death in pregnancy is:

	appendicitis
	trauma
	placental abruption
	thromboembolic disease
	ectopic pregnancy

20 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:

	About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry.
	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.

21 Pediatric airway question – Regarding viral croup, which of the following is FALSE?

	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.

22 Environmental emergencies question – Regarding black widow and brown recluse spider envenomations, which of the following is FALSE?

	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.
	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.

23 Trauma/Burn question – Criteria for transfer of a burn patient to a burn center include all of the following EXCEPT:

	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
	Chemical burns
	Electrical burns, including lightning injuries

24 Trauma question – Regarding replantation, which of the following is FALSE?

	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.
	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.

25 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?

	Children with nursemaid’s elbow typically have swelling and warmth around the affected elbow.
	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.

26 Toxicology question – Regarding digitalis intoxication, which of the following statements is FALSE?

	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.
	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.

27 Toxicology question – Regarding PCP intoxication, which of the following statements is FALSE?

	For severe intoxication, manifested by altered mental status and violent, agitated behavior, the treatment of choice is hemodialysis or hemoperfusion.
	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.

28 Toxicology question – The cardinal features of neuroleptic malignant syndrome (NMS) include all EXCEPT:

	altered mental status
	hyperthermia
	muscle rigidity
	vertical nystagmus
	autonomic nervous system instability

29 Toxicology question – Regarding isopropyl alcohol intoxication, all of the following would be expected EXCEPT:

	gastrointestinal and CNS complaints
	intoxicated behavior with the odor of acetone rather than ethanol on the breath
	anion gap acidosis
	an elevated osmolar gap
	hyperglycemia