#2 -- 2014-09-12 SAEM Tests Practice Questions 2013 Flashcards
The standard initial ACLS dose of IV epinephrine is: A. 0.1 mg 1:10,000 B. 10mg of 1:10,000 C. 1mg of 1:10,000 D. 1mg of 1:1,000
C. 1mg of 1:10,000
The answer is C. “Epinephrine remains the adrenergic drug of choice in the ACLS guidelines. The 2005 ACLS guidelines recommended the administration of 1 milligram IV or IO of a 1:10,000 solution every 3 to 5 minutes. Doses >1 milligram are not recommended and may be harmful.”
A patient with the rhythm shown in the Figure should be treated with: [image shows asystole] A. amiodarone B. verapamil C. defibrillationdefibrillation D. epinephrine
D. epinephrine
The answer is D. The flat line above is characteristic of asystole. This is mechanical
and electrical standstill. It is important to check that the monitor is working and to check
a second lead to rule out very fine ventricular fibrillation. The treatment of choice is
epinephrine or vasopressin and atropine
A 75 year old male is brought in by EMS with CPR in progress. He has been shocked three times and received 1 mg of epinephrine. His rhythm strip as shown in the Figure reveals: [image random up and down strokes] A. atrial fibrillation B. atrial flutter C. ventricular fibrillation D. ventricular tachycardia
C. ventricular fibrillation
The answer is C. Ventricular fibrillation is the totally disorganized depolarization and contraction of the ventricles. The EKG is characterized by a variable zig-zag pattern of very rapid, chaotic, and grossly irregular deflections of irregular appearance and varying amplitude. There are no discernible P waves, ST segments, T waves, or even QRS complexes.
A 50 year old male presents to the emergency department 1 week after having an acute myocardial infarction. He now complains of dizziness. His EKG, shown below, is characterized by:
[image all over the place]
A. normal sinus rhythm
B. complete heart block
C. second degree AV block Mobitz Type 2
D. second degree AV block Mobitz Type 1
B. complete heart block
The answer is B. In complete AV block, there is no relationship between the P waves (atrial beats) and the ventricular beats. The latter arises from different foci, thus the QRS complex is wide (impulse is not conducted through the normal pathways) and the rate is often slow at
Which of the statements below is correct regarding the two airway maneuvers depicted in the figure’s left (labeled “A”) and right (labeled “B”) aspects?
[image A:air into mouth B: chin lift jaw thrust]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving
A. Airway opening maneuvers such as those in the figure are not intended to affect the position of the tongue.
B. The left side of the figure (labeled A) depicts a jaw-thrust.
C. The maneuver depicted in the right side of the figure (labeled B) cannot be used in patients with suspected cervical spine injury.
D. Airway maneuvers such as those in the figure are only necessary in patients with complete airway obstruction.
E. The chin-lift maneuver risks spinal injury due to its employment of neck extension.
E. The chin-lift maneuver risks spinal injury due to its employment of neck extension.
The answer is E. In many patients in the Emergency Department, the inability to rule-out cervical spine injury negates the option to use the chin-lift maneuver, since this method of airway opening can exacerbate C-spine injury.
With respect to laboratory findings in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC), all of the following guidelines are generally true EXCEPT:
A. Serum bicarbonate is typically severely low ( 350 mOsm/L.
C. BUN is elevated more in patients with HHNC (>50 mg/dL) than in patients with DKA (25-50 mg/dL).
D. Patients with HHNC typically have blood glucose > 700 mg/dL, whereas patients with DKA have blood glucose > 350 mg/dL.
E. Serum ketones are present in patients with DKA but not usually in patients with HHNC.
A. Serum bicarbonate is typically severely low ( 15 mEq.
In a 70kg male DKA patient with serum glucose of 573 mg/dL, all of the following statements with regard to fluid and electrolyte imbalances are true EXCEPT:
A. A normal magnesium level is reassuring and obviates the need for magnesium replacement.
B. The patient is likely to be total body phosphorus depleted.
C. Total body water deficit is approximately 5L.
D. Serum sodium of 129 mEq represents dilutional hyponatremia and the corrected value is approximately 137 mEq.
E. Despite a serum potassium level of 4.8 mEq, the patient is probably total body potassium depleted.
A. A normal magnesium level is reassuring and obviates the need for magnesium replacement.
The answer is A. Patients with DKA are typically severely dehydrated with a total body water deficit of approximately 70-80 mL/kg, in addition to being total body depleted of potassium, magnesium, and phosphorous despite initially normal serum levels of these electrolytes.
Regarding the treatment of hyperosmolar hypertonic nonketotic coma (HHNC) and its associated symptoms, which of the following is correct:
A. Hyperosmolarity should be corrected within the first few hours in the emergency department.
B. Since patients are not acidotic, close monitoring of glucose is not necessary.
C. In HHNC patients with severe dehydration, bleeding diathesis is a major clinical concern.
D. Half of the fluid deficit should be corrected over the first hour and the remainder over the following 8 hours.
E. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.
E. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.
The answer is E. Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity.
Regarding the development of cerebral edema in patients being treated for DKA, all of the following are true EXCEPT:
A. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema.
B. Patients with serum glucose below 250 mg/dL still being treated with insulin are most likely to develop clinically evident cerebral edema.
C. Cerebral edema typically occurs six to ten hours following onset of treatment.
D. Children have a higher incidence of cerebral edema.
E. Mortality of patients developing cerebral edema is 90%.
A. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema.
The answer is A. Steroids are not indicated for treatment of cerebral edema and may actually worsen DKA. Mannitol 0.25-2.0 mg/kg should be administered upon any change in mental status of children being treated for DKA as they are at high risk for developing cerebral edema especially when being treated with insulin and serum glucose is below 250 mg/dL.
Of the choices below, the best treatment of the patient with hyperkalemia and EKG changes is: A. defibrillation B. vasopressin C. lidocaine D. amiodarone E. calcium
E. calcium
The answer is E. Hyperkalemia with EKG changes is treated with calcium to stabilize cardiac membranes. Calcium works quickly and is relatively safe unless patients are digitalized. Other treatments for acute hyperkalemia include sodium bicarbonate and insulin/glucose.
Which pharmacologic treatment for hyperkalemia works through stabilization of cardiac membranes? A. Magnesium B. Calcium C. Bicarbonate D. Insulin and glucose
B. Calcium
The answer is B. “Immediate antagonism of K+ at the cardiac membrane is achieved with IV administration of calcium chloride or gluconate. This is indicated in patients with unstable dysrhythmia or hypotension.”
A 55 year old female with a history of end-stage renal disease presents to the
emergency department with weakness. Her EKG is shown in the Figure, and reveals:
[image: peaked T waves]
A. hypocalcemia
B. pericarditis
C. hyperkalemia
D. acute MI
C. hyperkalemia
The answer is C. The EKG shows signs of hyperkalemia as characterized by diffuse peaked T waves. Other EKG changes include widening of the QRS complex and biphasic QRS-T segments. The heart rate may be slow, with ventricular fibrillation and cardiac arrest as the terminal events. Acute myocardial ischemia can be represented by hyperacute T waves as well, but in these cases the T wave changes are more likely to be focal (i.e. in an anatomical distribution corresponding to the area of threatened myocardium).
Regarding the diagnosis and treatment of hypoglycemia, which of the following is correct?
A. Patients who overdose on oral hypoglycemic agents such as sulfonylureas must have their serum glucose monitored for a minimum of 6 hours before emergency department discharge.
B. Patients with type 1 diabetes do not typically develop hypoglycemia.
C. Glucagon, administered intramuscularly or subcutaneously, is a safe and universally effective means for increasing blood sugar in hypoglycemic patients.
D. Hypoglycemia can present with virtually any neurological deficit.
E. Hypoglycemia in adults is typically symptomatic at or below serum glucose of 60 mg/dL.
D. Hypoglycemia can present with virtually any neurological deficit.
The answer is D. Glucagon is ineffective in patients without adequate glycogen stores, as would be expected in alcoholics. Further, glucagon can precipitate a severe lactic acidosis in patients with glycogen storage diseases and therefore should not be used in children with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include sweating, tachycardia, nervousness, hunger, and neurologic symptoms. Symptoms should not be attributed to hypoglycemia unless the level falls below 40-50 mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by skipping a meal, or by increasing energy output or insulin dose. Due to the extended half-lives of the oral hypoglycemic agents, hospitalization and 24-hour observation (at minimum) are the typical management for overdose of these agents.
A 20 year old man was ice skating on a frozen pond and fell through the ice. The water was only about six feet deep and he was able to keep his head above water while bystanders were able to extract him after 10 minutes. The patient was transported to the emergency department and had an initial core temperature of 30 C. The patient’s wet clothes were immediately removed and rewarming was initiated. Which of the following physical examination findings is expected? A. Tachycardia B. Hyperventilation C. Altered mental status D. shivering
C. Altered mental status
The answer is C. Moderate hypothermia is associated with temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea
A 36 year old male backpacking in the wilderness loses his way in a snowstorm. Temperatures are well below zero degrees and his clothing is inadequate. He is rescued 5 days later and presents to the ED. Rescue crew has already initiated passive rewarming and have removed patient’s damp clothing. On arrival, vital signs show pulse of 100 and temperature of 35.5C. On physical exam, you note patient has several toes that are purple with hemorrhagic blisters on his feet. Which of the following is the most appropriate initial management? A. Tetanus prophylaxis B. Administration of morphine C. Immersion in warm water bath D. Debridement of necrotic tissue
C. Immersion in warm water bath
The answer is C. Immersion of the affected extremity is the mainstay of treatment for patients with frostbite. Numbness of the affected area is the most common initial symptom and severe pain is frequently encountered after rewarming. Tetanus prophylaxis and debridement is indicated , but is not the most appropriate initial step in the management of patients with frostbite.
All of the following are true regarding the epidemiology of hypothyroidism EXCEPT:
A. Hypothyroidism does not occur in infants under six months of age.
B. Most cases of hypothyroidism manifest in the winter months.
C. Approximately half of myxedema cases are diagnosed after admission to the hospital.
D. Hypothyroidism occurs three to ten times more frequently in women than men.
E. Peak incidence of hypothyroidism is in the seventh decade.
A. Hypothyroidism does not occur in infants under six months of age.
The answer is A. Hypothyroidism may occur at any age including the very young, but is infrequently seen in infants due to regular newborn screening for hypothyroidism. The increased frequency of the disease in women is attributed to the increased prevalence of autoimmune thyroid conditions in women. The majority of cases present in winter months due to the body’s decreased ability to accommodate to cold weather in a hypothyroid state.
With regard to laboratory findings in hypothyroidism, which of the following is false?
A. Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels.
B. Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism.
C. Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism.
D. T3 level may be normal in hypothyroid states.
E. Free thyroxine (T4) is always depressed in hypothyroid states.
E. Free thyroxine (T4) is always depressed in hypothyroid states.
The answer is E. Free T4 may be normal in early stages of hypothyroidism due to physiologic compensation from elevated TSH levels.
Metabolic abnormalities often seen with hypothyroidism include all of thefollowing EXCEPT:
A. hyperglycemia
B. respiratory acidosis from hypoventilation
C. anemia
D. hyponatremia
E. hypercholesterolemia
A. hyperglycemia
The answer is A. Hyperglycemia is not typically associated with hypothyroidism. Hypoglycemia may be present, but is unusual, and may suggest hypothalamic-pituitary involvement. Hyponatremia is common and corrects with thyroid replacement. Hypercholesterolemia to over 250 mg/dL is typical. A mild normochromic, normocytic anemia may be present, in addition to respiratory acidosis from hypoventilation.
Laboratory abnormalities typically seen with adrenal insufficiency include all of the following EXCEPT: A. hypercalcemia B. azotemia C. hypokalemia D. hyponatremia E. hypoglycemia
C. hypokalemia
The answer is C. Hyperkalemia is seen in approximately 64% of patients with adrenal failure. Typically this is because of aldosterone production failure that normally enhances potassium excretion. Even more common is hyponatremia, present in 88% of patients. Hypoglycemia is present in two-thirds of patients and is a significant cause of morbidity and mortality associated with adrenal failure. Hypercalcemia is seen in 6 to 33% for unclear reasons; azotemia and increased hematocrit from hypovolemia may also be present.
Regarding the treatment of suspected but not confirmed adrenal insufficiency, which of the following is most appropriate?
A. hydrocortisone 100mg IV every 6 hours
B. cortisone 100mg IM every 6 hours
C. withholding of steroids until confirmation of the diagnosis of adrenal insufficiency
D. dexamthasone 4mg IV every 6 hours
E. cosyntropin 0.25mg IV x 1
D. dexamthasone 4mg IV every 6 hours
The answer is D. Dexamthasone is the treatment of choice in suspected but not confirmed adrenal insufficiency. It will not affect the serum cortisol level; therefore, it will not interfere with the diagnosis of adrenal insufficiency using the ACTH stimulation test. Administering cosyntropin, a synthetic form of ACTH, and measuring the serum cortisol levels typically perform the ACTH stimulation test. In confirmed adrenal insufficiency, hydrocortisone IV or cortisone IM are the treatments of choice.
Symptoms of secondary adrenal insufficiency include all of the following EXCEPT: A. nausea and vomiting B. weight loss C. weakness D. anorexia E. hyperpigmentation
E. hyperpigmentation
The answer is E. Hyperpigmentation is seen in greater than 90% of primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion. The secretion is a feedback mechanism that is not activated in secondary adrenal insufficiency, for example, adrenal insufficiency from pituitary infarction or hypothalamic insufficiency.
Treatment with hyperbaric oxygen (HBO) is associated with contraindications. Which of the following is not a relative or absolute contraindication to HBO? A. COPD with air trapping B. pregnancy C. otitis media D. untreated pneumothorax
B. pregnancy
The answer is B. Untreated pneumothorax is an absolute contraindication to HBO therapy. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy. The COPD patient with a large bleb represents a relative contraindication for similar reasons. Treatment with doxorubicin, and many other drugs – such as cisplatin (Cisplatinum®), bleomycin (Blenoxane®), disulfiram (Antabuse®), and mafenide acetate (Sulfamylon®) – contraindicates HBO therapy because of potentially toxic effects when combined with HBO. URI illnesses such as otitis media are relative contraindications, due to the potential for tympanic membrane rupture secondary to inability of the ears to equalize pressure during therapy. This can be addressed through myringotomy with placement of tubes (in cases where multiple HBO treatments are anticipated). In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and “doses” (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed pregnant patients. This is due to the high affinity of fetal hemoglobin for CO.
Which of the following is NOT a potential indication for hyperbaric oxygen therapy? A. necrotizing enterocolitis B. necrotizing fasciitis C. carbon monoxide poisoning D. decompression sickness
A. necrotizing enterocolitis
The answer is A. According to the Undersea and Hyperbaric Medical Society, items A-D are all reasonable indications for the use of hyperbaric oxygen therapy. Other potential indications include patients with air or gas embolism, crush injury, and compartment syndrome.
A 23 year old college novice mountain climber decides to climb a mountain with friends as a graduation present. His first night is spent at an altitude of 8,500 feet at a mountain resort. The next morning he starts to experience a mild headache and nausea. His symptoms get worse throughout the day. His friends want to get to 10,000 feet by nightfall. As a physician at the hotel, the worst advice you can give him is: A. Take acetazolamide. B. Take ibuprofen. C. Ascend with the rest of the team. D. Take supplemental oxygen.
C. Ascend with the rest of the team.
The answer is C. The syndrome of high altitude illness ranges from mild AMS (Acute Mountain Sickness) to life threatening conditions of HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). This student is experiencing mild AMS. After the symptoms of altitude illness occur, further ascent to a higher sleeping altitude is contraindicated. Halting ascent or activity to allow further acclimatization may reverse symptoms. Acetazolamide is a carbonic anhhydrase inhibitor that induces a renal bicarbonate diuresis, causing a metabolic acidosis and thereby increasing ventilation and arterial oxygenation. Supplemental oxygen addresses the hypoxic insult of high altitude exposure. Ibuprofen is useful for the treatment of his headache. Dexamethasone can help with the symptoms of AMS, but does not play a role in acclimatization.
A 65-year-old female presents with a chief complaint of palpitations and dyspnea on exertion. Vital signs are BP 130/84, HR 160 (and irregularly irregular), RR 14, T 37.8. EKG shows a narrow complex, irregularly irregular rhythm with absence of p-waves and an undulating baseline. What endocrine abnormality is most likely to be a direct cause of this abnormal rhythm? A. Cushing's syndrome B. Hyperthyroidism C. Hyperparathryoidism D. Addison's disease
B. Hyperthyroidism
The answer is B. Atrial fibrillation is a common arrhythmia. Its hallmark is the absence of P waves and irregular rhythm. It is associated with many medical conditions including ischemic heart disease and thyrotoxicosis. Atrial fibrillation increases the risk of thrombus formation and arterial embolism. AF’s many treatment options include calcium channel blockers, beta blockers, amiodarone, quinidine, and cardioversion. Pacing is not a treatment option.
Regarding the diagnosis and treatment of thyroid storm in the emergency department, which of the following is true?
A. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease.
B. Thyroid storm cannot be diagnosed in the absence of altered mental status.
C. The diagnosis of thyroid storm is generally a straightforward clinical diagnosis and rarely confused clinically with other disorders such as psychiatric or other endocrine disorders.
D. A stat thyroid-stimulating hormone (TSH) level is required to make the diagnosis.
E. Treatment of thyroid storm should only be undertaken after consultation with an endocrinologist.
A. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease.
The answer is A. The diagnosis of thyroid storm in the emergency department may be challenging due to the relatively infrequent occurrence of the disease and its typically nonspecific signs and symptoms. Treatment should be initiated in a timely fashion in any patient suspected of having thyroid storm due to the potential lethality of this disease. Immediate laboratory testing is typically not available to confirm clinically suspected cases, although thyroxine (T4) radioimmunoassay and free T4 index are good screening tests for hyperthyroidism. Clinical presentation of thyroid storm may be mistaken for psychiatric illness, heat stroke, sympathomimetic toxidromes, hypoglycemia and withdrawal syndromes, among others. Altered mental status, though frequently present, is not a prerequisite for diagnosis.
Which of the following is not a common sign or symptom of thyrotoxicosis? A. hyperhidrosis B. nervousness C. tachycardia D. congestive heart failure E. hypothermia
E. hypothermia
The answer is E. Fever, not hypothermia, is commonly seen in thyrotoxicosis. Other common signs and symptoms include tachycardia, congestive heart failure, wide pulse pressure, tremor, thyrotoxic stare, thyromegaly, nervousness, weight loss, and palpitations.
Which of the following is true regarding the use of iodine in the treatment of thyroid storm?
A. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given.
B. Dexamethasone must be given 30 minutes prior to iodine administration.
C. Iodine should be administered even in patients with known iodine allergy.
D. Iodine should be the first drug administered in the treatment of thyroid storm.
E. Iodine should be administered only after treatment with propranolol.
A. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given.
The answer is A. Iodine inhibits preformed thyroid hormone release and should be administered at least one hour after treatment with PTU to prevent organification of iodine. A typical dose is potassium iodide (SSKI) 5 drops every 6 hours PO or NG, or sodium iodide 1 gm slow IV drip every 8 to 12 hours. Iodine should not be administered to patients with known iodine allergy.
