Emergency Medicine

Question 1

Major risk factor for coronary artery disease or MI in teenage population.

Answer 1

Cocaine use

-leads to myocardial oxygen deprivation thru coronary vasoconstriction

Question 2

When a patient presents to the ER with chest discomfort when should an EKG be performed?

Answer 2

Hopefully within ten minutes of arrival.

Question 3

What type of test checks for a right ventricle MI?

Answer 3

Right sided EKG

-look specifically at lead rV4 for ST elevation

Question 4

In the ER, which symptoms should NEVER exclude acute MI?

Answer 4

Reproducible chest pain

most of the time it indicates MSK etiology but in rare cases it can be indicative of MI

Question 5

What is MONA therapy.

Answer 5

Therapy used in patients suspected of any acute coronary syndrome.
Morphine, Oxygen, Nitrates, ASA

Question 6

What are contraindications for nitrate therapy?

Answer 6

Hypotension (<90 mmHg sbp)

-possible caused by ED meds, the nitrates dilate coronary vasculature and further drop bp

Question 7

When is the ideal time for fibrinolytic therapy?

Answer 7

For acute STEMI within a 30 minute time frame of admission to the ER
(if a cath lab is available, that should be the first choice)

Question 8

What is the ideal time frame for PCI (like balloon therapy) in patients presenting with ACS?

Answer 8

Within 90 minutes of admission

Question 9

What is the use of cardiac markers in the ER?

Answer 9

Used to “rule in” MI, however, the absence of a positive marker test does NOT “rule out” MI.

Question 10

What is the population distribution that most commonly develops abdominal aortic aneurysms (AAA)?

Answer 10

Elderly Males

Question 11

Which layer of the blood vessel is weakened in AAA?

Answer 11

Media Layer

Question 12

What diameter measurement of the aorta classifies it as an AAA?

Answer 12

> 3cm

Question 13

What does Laplace’s Law state?

Answer 13

The size of the aneurysm directly correlates to the speed of its progression. Basically as they get larger, the rate of growth also increases.

Question 14

What is the classic presentation of AAA?

Answer 14

Syncope without warning followed by abdominal and lower back pain. PE will show hypotension and pulsatile abdominal mass.

Question 15

What are Cullen and Grey Turner signs?

Answer 15

Cullen: periumbilical ecchymoses
GT: flank ecchymoses
-both indicate retroperitoneal hematoma

Question 16

What is a GI complication of AAA?

Answer 16

Aortoenteric fistula causing GI bleeding.

Question 17

What diameter measurement puts an AAA at highest risk of rupture?

Answer 17

> 5cm

Question 18

Test to confirm diagnosis of AAA in stable patients vs. unstable.

Answer 18

Stable: CT
Unstable: US
(imaging is not required to begin treatment for suspected AAA)

Question 19

What is treatment for AAA in the ER.

Answer 19

Early blood transfusion but care not to overtransfuse (can lead to excessive bleeding).
-patient should then be taken to surgery for endovascular repair

Question 20

Population distribution for aortic dissection (AD).

Answer 20

Bimodal

• young usually with congenital vascular pathology
• elderly with lifestyle risk factors

Question 21

Other than congenital conditions like Marfanism, what can illicit AD in a younger population?

Answer 21

Cocaine or Amphetamine use

Question 22

Which layer of the blood vessel is torn in AD?

Answer 22

Intima layer

Question 23

What is a Type A vs. Type B AD?

Answer 23

Type A: involves ascending aorta
Type B: does not

Other classification:
Type I: involves ascending and descending
Type II: just ascending
Type III: just descending

Question 24

What is the presentation of AD?

Answer 24

Sudden sharp chest pain that may radiate between the shoulder blades.

Question 25

What type of medications are absolutely contraindicated to treat AD?

Answer 25

Thrombolytics

Question 26

What can be seen on CXR that might indicate AD?

Answer 26

Mediastinal widening, aortic knob abnormalities (calcification), trachea deviation, left pleural effusion

Question 27

What is the gold standard for AD diagnosis?

Answer 27

Dx: angiography

-imaging is necessary to diagnose and treat AD

Question 28

What is the first line ER treatment for confirmed AD?

Answer 28

Beta Blockers to lower HR (CCB can be used if allergy or COPD)

Nitrates can also be used to lower BP.

Question 29

How is Type A treated vs. Type B?

Answer 29

Type A: surgically

Type B: with meds