Kaplan Flashcards
A frantic mother brings her 4 year old daughter to the emergency room after discovering that the child had drunk from a bottle of drain cleaner. The girl complains of severe burning pain in her throat and chest. She is breathing well and has no significant findings of physical examination. Which is the appropriate management in this patient? A. Carbón activado B. Lavado gástrico C. Ipecac (emético) D. Rx de tórax y abdominal E. Neutralización
D. Rx de tórax y abdominal: Primero es importante tener la vía aérea asegurada, luego se deben tomar radiografías para ver si hay aire libre en el mediastino por perforación esofágica o debajo del diafragma por perforación gástrica.
La E neutralización no es ya que con un ácido débil puede resultar en producción excesiva de calor y aumentar el riesgo de emesis.
A 78-year-old woman is brought to the emergency room by her son for evaluation of palpitations.
The patient has a history of atrial fibrillation and is rate controlled with digoxin. She was also
recently prescribed antibiotics for treatment of a mild case of bronchitis. Which of the following
antibiotics is associated with digoxin toxicity?
A. Ampicillin B. Cephalexin C. Ciprofloxacin D. Clarithromycin E. Penicillin
La correcta es la D: macrolidos. Macrolides (specifically erythromycin and clarithromycin) and
tetracyclines have been shown to increase digoxin levels. These two classes of antibiotics can
alter the gastrointestinal flora that typically metabolize digoxin, which can in turn lead to higher
levels of digoxin and possible toxicity.
A 76-year-old woman with mild dementia is brought to the emergency room by her daughter for
evaluation of shortness of breath, nausea, and vomiting. She states that her mother had recently
had a flare of her arthritis and had been taking more aspirin pills than usual. When she visited her
mother in the morning, there were two empty bottles of aspirin at her bedside. Which of the
following is the most appropriate therapy for this patient?
A. Fluid restriction
B. Laxatives
C. N-acetylcysteine
D. Permissive hypokalemia
E. Urinary alkalinization
The correct answer is E. This patient has likely salicylate toxicity. Urinary alkalinization enhances salicylate elimination by promoting the ionization of salicylates, thus preventing
reabsorption in the renal tubules. Alkalinization of urine/serum can be achieved by
administration of sodium bicarbonate either as boluses or a continuous infusion of sodium
bicarbonate with 5% dextrose. The administration of activated charcoal (1 mg/kg) to all
patients with suspected toxic ingestions is appropriate. In addition, whole-bowel irrigation
with polyethylene glycol can be useful in reducing absorption in cases of suspected bezoar
formation, as well as in cases of enteric-coated aspirin ingestion. Hydration and correction of
electrolyte abnormalities are crucial, thus fluid restriction and permissive hypokalemia are incorrect (choices A and D). Regular laxatives (choice B) are ineffective when compared to polyethylene glycol used for whole bowel irrigation. N-acetylcysteine (choice C) is used in cases of acetaminophen toxicity.
A 26-year-old woman is brought into the emergency room after a suicide attempt by ingestion of
antidepressant medication. She had recently broken up with her boyfriend, whom she called to
tell about her intention to commit suicide. He states that she had been seeing a psychiatrist who
prescribed tricyclic antidepressants to treat her depression. In the emergency room, she is
stuporous. Her temperature is 38°C (100.4°F), blood pressure is 90/40 mm Hg, pulse is 139/min,
and respirations are 7/min. During the initial evaluation, the patient begins to have a tonic-clonic
seizure, which resolves with the administration of lorazepam. Which of the following is the
appropriate next step in management?
A. Activated charcoal
B. Endotracheal intubation
C. Hemodialysis
D. Physostigmine
E. Serum alkalinization
The correct answer is B. For all patients with possible tricyclic antidepressant (CA) toxicity, the ABCs of resuscitation must be initiated. In a patient presenting with seizures, airway protection, ventilation, and oxygenation are particularly important. This should be followed by resuscitation with intravenous fluids, cardiac monitoring, and obtaining an electrocardiogram.
A 78-year-old female with recent hip replacement surgery is brought to the emergency room after being found unresponsive at home. She was intubated by EMS before arrival. Upon closer inspection of the patient’s home medications, the physician realizes that the narcotics prescribed for pain are triple the dose she had been given in the hospital. Which of the following is the next appropriate step in the management of this patient?
A. Monitor the patient
B. Replacement of the ET tube with a surgical airway
C. Administration of naloxone
D. Obtain chest radiographs to ensure proper ET tube placement
E. Obtain blood cultures to evaluate for sepsis
The correct answer is C. The patient is likely experiencing acute opiate overdose due to
her prescribed dose of narcotics. In opiate naive patients, the treatment for reversal of opiate
overdose is naloxone. The most commonly used dosages for reversal in an emergency setting is 0.4-2 mg IV initial dose repeated as needed every 2-3 minutes, up to a maximum
of 10 mg, until the desired response. Other methods of administration include intranasal, endotracheal, and continuous infusion.
An 18-year-old male is brought into the emergency room by EMS after having a seizure at the airport. He had just arrived on an 8-hour flight from Guatemala, His temperature is 104°F (40°C), blood pressure is 180/50 mm Hg, pulse is 150/ min, and respirations are 35/min. On physical examination, the patient's pupils are dilated and his abdomen is distended with absence of bowel tones. An abdominal x-ray reveals multiple radiodense foreign bodies in the small bowel and colon. Which of the following is the most likely agent responsible for this patient's condition? A. Benzodiazepines B. Cocaine C. Heroin D. Ketamine E. Mescaline
The correct answer is B. This patient is a drug mule with cocaine toxicity from a ruptured packet of cocaine. Patients with cocaine toxicity will present with hyperthermia, tachycardia or tachyarrhythmias, and tachypnea. They may present with a variety of central nervous system manifestations including seizures, agitation, delirium, coma, and convulsions.
A 36-year-old male is undergoing conscious sedation with midazolam in the emergency room for drainage of a perianal abscess. During the procedure he becomes apneic. Which of the following medications should be administered? A. Ethanol B. Flumazenil C. N-acetylcysteine D. Naloxone E. Physostigmine
The correct answer is B. Flumazenil is a competitive antagonist of benzodiazepine receptors that can be used to reverse overdose. However, routine use in patients with oversodes of
unknown or mixed etiology is not recommended as the risks to the patient outweigh the benefits of flumazenil. In the controlled post-op or post-procedural setting (as in this patient)
Flumazenil is used to reverse oversedation.
A 16-year-old male is brought to the emergency room by his friends because of abdominal pain, vomiting, and altered mental status. He was at a party with his friends who state that he refused
to drink alcohol and was instead taking his mother’s migraine pills to relax. In addition to barbiturates, toxic levels of which of the following substances are most likely to be present in this
patient?
A. Acetaminophen B. Diazepam C. Lorazepam D. Methadone E. Morphine
The correct answer is A. Barbiturates are less commonly used since the advent of
benzodiazepines. They are, however, still commonly found in migraine medication as a
combination with acetaminophen or a salicylate. Determination of the exact medication is important in order to initiate appropriate therapy. Benzodiazepines and narcotics can also be found in conjunction with barbiturate toxicity, as multidrug toxicity is common. In this patient, however, if single-medication overdose from migraine medication is suspected, the most likely additional agents are still acetaminophen and salicylates. Early symptoms of acetaminophen
toxicity include nausea, vomiting, and abdominal pain. At later stages when hepatic injury progresses, jaundice, altered mental status, and coagulopathy occur.
An 18-year-old male is brought by EMS to the emergency room after he jumped off a bridge. He
did not sustain any obvious injury, but he is severely agitated. He admits to taking lysergic acid
diethylamide (LSD) prior to the event. Which of the following agents can be used in the management of this patient?
A. Activated charcoal B. Benzodiazepines C. Flumazenil D. Gastric lavage E. Naloxone
The correct answer is B. Patients who present after ingestion of LSD can first be approached
with reassurance in a calm, stress-free environment. Excessive agitation can be treated with benzodiazepines if placing the patient in a stress-free and calming environment does not calm the patient. Activated charcoal (choice A) and gastric lavage (choice D) are not useful because LSD is rapidly absorbed into the gastrointestinal tract. Flumazenil (choice C) is used for benzodiazepine toxicity. Naloxone (choice E) is used for opioid toxicity.
How long after ingestion should a plasma level for acetaminophen be measured? A. 21 hour B. ≥4 hours C. =8 hours D. 216 hours E. 224 hours
The correct answer is B. The Rumack-Matthew nomogram is still used for an acute
single ingestion of acetaminophen (not chronic). It is a semilogarithmic plot of
acetaminophen serum concentration in ug/mL versus hours after ingestion.
Acetaminophen absorption may be delayed 4 hours in overdose and so serum
concentrations prior to 4 hours after ingestion are not interpretable. Therefore, a plasma level for acetaminophen should be measured >4 hours after ingestion. It also should not be used with a multiple substance ingestion as other substances taken with acetaminophen may alter gastrointestinal motility.
Which of the following clinical findings is more likely associated with the first stage (first 24 hours) of acetaminophen poisoning? A. Fulminant hepatic necrosis B. Peak liver function abnormalities C. Prolonged prothrombin time D. Right upper quadrant (RUQ) pain E. Vomiting
The correct answer is E. Acetaminophen toxicity is due to an intermediary metabolite combining with hepatic macromolecules to produce hepatocellular necrosis. A single toxic
dose in children is >150 mg/kg. There are four stages of acetaminophen poisoning if the patient is left untreated; however, the initial signs of nausea and vomiting are nonspecific and are not present in some children. Therefore, the clinician must make the possible diagnosis based on the history, symptoms and laboratory findings. The only abnormal laboratory finding initially is the acetaminophen level.
Which of the following effects of alcohol is most likely seen at an alcohol level of 50 to 150Bmg/dL? A. Blurred vision B. Hypoglycemia C. Slurred speech D. Staggering E. Stupor
The correct answer is A. Alcohol causes more deaths in children and adolescents in the U.S. than all other illicit substances combined. It acts mainly as a central nervous system depressant and high levels may cause respiratory depression (most common reason for death). The effects of alcohol depend on the level. In most states, a person is considered
medicolegally intoxicated at 100 mg/dL. Serum levels >200 mg/dL are associated with a risk of death and levels >500 mg/dL are usually fatal.
50-100 mg/dL Incoordination, blurred vision, slow reaction time
150-300 mg/dL Visual impairment, staggering, slurred speech
300-500 mg/dL Stupor, hypoglycemia, coma
>500 mg/dL Fatal, if no tolerance
Which of the following clinical signs or symptoms is most likely associated with a salicylate serum level of 85 mg/dL 6 hours after ingestion? A. Convulsions B. Fever C. Lethargy D. Mental confusion E. Vomiting
The correct answer is A. The earliest signs of salicylate toxicity are nausea, vomiting, diaphoresis, and tinnitus. Salicylates stimulate the respiratory center. In moderate toxicity,
tachypnea and hyperpnea with tachycardia begin to appear. Insensible losses from vomiting, tachypnea, diaphoresis, and uncoupling of oxidative phosphorylation lead to tachycardia. With severe toxicity, findings include hyperthermia, seizures and coma. Serum salicylate levels should be monitored every 2-3 hours until they start to decrease. An acute dose of >150 mg/kg is considered to be significant with mild to moderate toxicity produced
up to a 300 mg/kg dose and serious toxicity at >300 mg/kg to 500 mg/kg. Greater than 500 mg/kg is potentially lethal. A serum level approach 100 mg/dL is associated with serious
toxicity. Peak levels do not occur until 4-6 hours after ingestion and a 6 hour level of >100 mg/dL is potentially lethal.
Which of the following acid-base disturbances is more commonly associated with acute
salicylate toxicity?
A. Chloride-resistant metabolic alkalosis
B. Chloride-responsive metabolic alkalosis
C. Non-anion gap metabolic acidosis
You did not select. This answer is incorrect
D. Respiratory acidosis
E. Respiratory alkalosis
The correct answer is E. Phase 1 of salicylate ingestion causes respiratory alkalosis from hyperventilation due to direct stimulation of the respiratory center, and potassium and
bicarbonate are secreted in the urine. In phase 2, alkalosis continues and a “paradoxical aciduria” occurs. Phase 3 presents with an anion-gap metabolic acidosis due to lactic acidosis as aspirin impairs the Krebs cycle, as well as dehydration and hypokalemia (this phase may appear as early as 4 to 6 hours after ingestion).
Which of the following types of necrosis is more common with alkali ingestion? A. Caseous B. Coagulative C. Fat D. Gangrenous E. Liquefaction
The correct answer is E. Alkalis produce liquefaction necrosis, saponification of fats, denaturation of proteins, and thrombosis of blood vessels with the risk of perforation. Acids cause coagulation necrosis, which forms an eschar preventing deep penetration into the
tissues and perforation.
