ER MEDICINE REVIEW

1. Abdominal Pain
a. Pancreatitis (RANSONS criteria)
b. Diverticulitis
i. LLQ,
ii. Increased WBC
iii. No bleeding
2. Esophageal rupture
3. Boerhaves
a. Crepitus
b. Hamans crunch
4. Pain out of proportion = ischemia (mesenteric)
a. Have high index of suspiciaon
b. Looks like drug abuse patient
c. Risks- afib, protein/cns deficiency. Chf(low flow state)
5. Stomach tearingAAACT scan/US
6. Funny sensation in leg Dissection
a. Artery of Adamkerwitz-lack of flow to spinal cord causeing sensory problems
secondary to dissection
7. Perforated bowelmechanical volvulus ulcer
a. U/S for appendicitis
8. Ingestion of battery go get it
9. Alcoholics – withdrawl  asterixis (see in cirrhosis as well)
a. Can OD if you think alcoholic benzo b/c of 1st pass
10. Bannana bag = multivitamins and thiamine (B1)
11. ACLS
12. 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 mode
15. Contraindications for thrombolytics (not if cath is available) – aortic dissection, brain
bleed,
16. Cardiac rhythm
a. V.tach
b. V.fib
17. Don’t give nitroglycerins w/erectile dysfunction
18. Kawasaki  aneurysms  give aspirin
a. Strawberry tongue, diffuse rash, injected conjunctiva
19. Thoracic dissection

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 a. Ripping pain to back
i. Aortography
ii. CT-A
iii. Transesophageal echo
iv. CXR – see loss of AP windoe, widened mediasteinym, deviation of
trachea
v. 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 tamponade
a. JVD, decr. BP, muffeled heart sounds (Becks triad)
21. Cardiomegaly/CHF mgmt
22. Weak after MI  Dresslers syndrome
23. Endocarditis-tripod, st-elevations
24. PE –sharp inspiratory chest pain
25. Metabolic
a. Hyperkalemia – give insulin, calcium to protect cardiac cells, MCC lab error due
to cell damage when drawing bloodREPEAT
b. Hypokalemia
c. Hypernatremia/Hyponatremia
26. Story doesn’t match picture  Abuse
27. Impetigo  staph/strep
28. IV fluids for fluid replacement for kid  same as an adult  NS or LR 20ml/kg bolus
29. Febrile seizures  work up
30. Hip pain ddx
a. Leg-calf-Perthes
b. Avascular necrosis of femoral head
c. Slipped cap femoral epthasis

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 31. Hand-foot-mouth disease
a. Coxsacchi B
32. Rash palms and soles
a. Secondary syphilis
b. Rocky mountain spotted fever
c. Psoriasis
33. Upper Respiratory Obstruction
a. Foreign body
b. Epiglottisis
c. Retropharyngeal abscess
d. Angioedema
e. Croup
f. Pharyngitis
34. Periorbital cellulitis
a. Pt looks really sick
b. Cant move eye b/c of deep infection behind eye
35. Baker Act
a. Can be done by any liscensed physician/policeman
b. Hold for psych
36. Visual hallucinations = most likely due to a medical reason
37. Auditory hallucinations = most likely due to psychitric reason
38. Hysterical blindness
a. Somatic complaints but all psych
39. Tension pneumo
a. Needle decomplression f/u chest tube
b. 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 elbow
a. Flex, supinate with thumb at radial head
b. Feel pop
41. Unconscious patient
a. SNOT (sugar, --,--, thyamine (from werkickies)
42. Intubate  next step = check tube placement
43. Trauma and blood at meatus  retrograde urethrogram
44. ABC’s Trauma
45. FAST
a. If + and hypotensive  laporotomy
46. Gun shot wound and see bullet in belly  laporotomy
47. Chest trauma
48. Flail chest
49. Glascow Coma score
50. Epidural vs subdural hematoma on CT
51. 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 departm
has mild posterior neck tenderness. A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-
there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most approp

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 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 formula
b. Rule of 9’s
c. Give 4ml/kg/%body area burned
i. Half must be given in first 8 hrs
53. Pain over snuff box  FOOSH  fx of scaphoid
54. Lightning
55. Near drowing
a. Salt vs fresh
56. AMA/medical legal
a. Jahovas witness
b. 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 = NPH
60. Posterior circulation ischemia – stroke
61. Double vision (not just double vision) = MAJOR problem
a. Mass or pituitary tumor
62. Worst HA of life = subarachnoid hemorrhage
63. Shingles at tip of nose  worry abt herpes opthalgia
64. Nervous system DZ
a. MS
b. Guillan barret
c. Myastenia gravis
65. Meningitis prophylaxis
66. Transient loss of vision in one eye  Amorosis fugax
67. Seizure  tx is benzo
68. 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,
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.

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 b. CHR -S1 Q3 T3 pattern
69. COPD/Asthma tx
a. Give Epi if dying
70. Give O2 and CO2 goes up
a. CO2 narcosis
71. Metabolic Acidosis
a. MUDPILES and Carbon Monoxide
72. Tricyclic antidepressant OD
a. Anticholinergic sx, seizures
73. Worry about OD’s with drugs that have long acting half lives
a. Same with long acting BP meds
74. ASA/Acetaminophen OD’s
75. Organophosphate OD
76. Toxic ingestion
77. OBGYN
a. Ectopic pregnancy (see in 5-8 weeks usually; not at 12)
b. Bartholins abscess
c. PID vsTuboovarian abscess vs Torsion – horrible pain  US
d. Toxic shock from tampon

Abdominal Pain
Regarding 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.

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.

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 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 antacids
B. pain that is worse preceding a meal
C. unrelenting pain over a period of weeks

D. pain that awakens a patient in the middle of the night

E. 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. intussusception
B. appendicitis

C. pyloric stenosis
D. constipation
E. 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.
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

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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 examinations

B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Discharge home after a single dose of IV antibiotics
D. 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 inflammation

B. Lesions are typically contiguous
C. There is a small increased risk of colon cancer
D. 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 hematoma

C. Ruptured spleen
D. Small bowel obstruction
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).

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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 constipation

B. marathon running
C. pregnancy
D. age 25-35
E. 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 spleen
B. sacral pain—ovarian torsion
C. epigastric pain—myocardial infarction
D. inguinal pain—ureteral colic
E. thoracic back pain—pancreatitis
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.

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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 fluids

C. type and cross two units of packed red blood cells
D. immediate surgical intervention
E. 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-
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.

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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 leads

B. ST-segment depression of at least 2mm in any precordial lead
C. Atrial fibrillation with a rapid ventricular response
D. 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-dimer
C. EKG with right-sided leads
D. 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 MI
B. unstable angina
C. anteroseptal MI
D. pericarditis
E. 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
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 hours

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 B. Urgent placement of a cardiac pacemaker
C. 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 urgency
B. moderate hypertension
C. white-coat hypertension
D. acute hypertensive (non-emergency/non-urgency) episode

E. hypertensive crisis
The 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. Lidocaine
B. Lorazepam

C. Metoprolol
D. 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
site has a yellowish tinge without blood. Of the following choices, which is the most appropriate
management for this patient?
A. No specific treatment required
B. Immediate dental consult to avoid abscess formation
C. Replace fractured piece and place acrylic splint

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 D. Application of calcium hydroxide, placement of aluminum foil, and dental follow-
up

E. Placement of tooth fragment in saline gauze, outpatient dental follow-up

The 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 injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus

E. tenderness over the talus

The 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 status

B. ascertainment of intraocular pressure via tonometry
C. ophthalmology consultation
D. visual acuity assessment
E. 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 fracture

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

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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. proptosis
C. diplopia with upward gaze
D. anesthesia of the right infraorbital region
E. 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 observation

B. Immediate operative exploration
C. Local wound exploration and discharge home if no significant injury identified
D. Local wound exploration and discharge home after 6-hour observation period
E. 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.

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

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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 kidneys
B. CT abdomen / pelvis with IV contrast alone
C. CT abdomen / pelvis with IV and transurethral contrast
D. Ultrasound of the bladder

E. CT abdomen / pelvis without contrast

The 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 transport
The 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 stable
Answer is E

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

A. Wrist drop
B. Weakness of finger adduction

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 C. Decreased sensation over the hypothenar eminance
D. Weakness with flexion at the finger MCP joints
E. 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 fracture

B. Posterior hip dislocation
C. Subtrochanteric femur fracture
D. Intertrochanteric femur fracture
E. 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% oxygen
C. Chest tube placement
D. 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]
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 symptoms

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 B. The patient likely has symptoms on only one side of the his body
C. The patient likely has paralysis and loss of sensation to pain and temperature
bilaterally below the lesion
D. 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 consciousness
B. Deep burns
C. Cardiac arrest

D. Fractures or dislocations
The 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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