Mock Exam Part 2, #1-15 Reviewer

Question 1

Standard of care for the treatment of AMS (Mild to moderate)

Answer 1

Acetazolamide

dose of 125-250 milligrams PO twice daily

Question 2

reserved for cases of moderate to severe AMS because of potential side effects

Answer 2

Dexamethasone

Dose of 4 milligrams PO, IM, or IV every 6 hours

Question 3

Used in the prevention and TREATMENT of HAPE

But NO value in AMS or HACE

not necessary if supplemental oxygen available

Answer 3

Nifedipine

Dose of 20–30 milligrams extended-release PO every 12 h

Question 4

Adverse effects of Acetazolamide

Answer 4

Common: paresthesias, polyuria, altered taste of carbonated beverages
Less common: drowsiness, nausea

Question 5

What is SUBMERSION vs IMMERSION?

Answer 5

SUBMERSION
> majority of drowning
> patient goes under water, suffers hypoxic cardiac arrest, develops hypothermia
> unlikely to benefit from prolonged resuscitation EXCEPT children

IMMERSION
> less common
> immersed in cold water but able to breathe air, cooling ensues, and the patient eventually suffers a presumed hypothermic cardiac arrest and may or may not become secondarily submerged
> benefits from prolonged resuscitation

Question 6

first definitive step of frostbite therapy

Answer 6

Rapid rewarming

should be initiated as soon as the risk of refreezing injury can be avoided

Question 7

In rewarming frostbite, place the injured extremity in gently circulating water heated to a temperature of _________°C for approximately 20 to 30 minutes, until the distal extremity is pliable and erythematous.

Answer 7

37 to 39 deg C

Question 8

The cardinal features of heat stroke are

Answer 8

hyperthermia >40°C

and

altered mental status

Question 9

Management of Stingray Injuries

Answer 9

> Irrigate wound
Remove visible pieces of the spine
Control bleeding and immerse in hot water
During hot water soak, the wound can be explored and foreign material removed
Provide oral or parenteral analgesics
Obtain SOFT TISSUE IMAGING to visualize retained foreign material

Question 10

In Stingray injuries hot water submersion between temperature of __________°C can denature the venom protein and provide pain relief within 10 to 30 minutes

Answer 10

43.3°C and 45.6

Question 11

Clinical indications for immediate antivenom therapy

Answer 11

evidence of neurotoxic effects (ptosis, cranial nerve involvement, progressive muscle weakness, or diaphragmatic involvement)

coagulopathy
rhabdomyolysis
renal failure
cardiac collapse
significant local tissue injury
vomiting unresponsive to antiemetics

Question 12

Administration of Snakebite (Elapid) ANTIVENOM

Answer 12

IV always.

If IV access is unavailable, consider IO administration.

IM administration is strongly discouraged due to slow absorption and potential complications of anticoagulation.

Skin testing before antivenom administration is not recommended

Dilute anti- venom about 1:10 in normal saline, then infuse 20 to 30 mins

Same dose in children

5-day course of steroids (e.g., prednisone, 1 milligram/kg PO once daily) may be prescribed to reduce the incidence of serum sickness, but lacks evidence

Question 13

The clinical conditions of barotrauma of ASCENT

Answer 13

Mnemonic:
Akyat na dahil VERy DEEP na

VERtigo (alternobaric)
DEcompression sickness,
Embolism (arterial gas) - neurologic symptoms
Pulmonary barotrauma - Dyspnea, chest pain, subcutaneous air, extra-alveolar air on radiograph

Question 14

clinical conditions resulting from barotrauma of DESCENT

Answer 14

Kapit ka (Squeeze) kapag BABABA

BArotitis (ear squeeze),
external ear Squeeze,
sinus BArotrauma,
inner ear BArotrauma,
and face, tooth, or dry-suit Squeeze

Ear Squeeze - Pain, fullness, vertigo, conductive hearing loss from inability to equalize middle ear pressure

Sinus barotrauma - Pain over affected sinus, possible bleeding from nares

Inner ear barotrauma- Sudden onset of sensorineural hearing loss, tinnitus, severe vertigo after forced Valsalva

Question 15

What TYPE of Decompression Sickness (DCS) presents with

Deep pain in single joint (knee/ shoulder) and extremities, unrelieved but not worsened with movement

Skin changes—mottling, pruritus, and color changes

Answer 15

Type I: “pain-only” DCS

Question 16

What TYPE of Decompression Sickness (DCS) presents with

Pulmonary (“chokes”)—cough, hemoptysis, dyspnea, and substernal chest pain

Cardiovascular collapse can occur

Neurologic—sensation of truncal constriction, ascending paralysis, usually rapid in onset

Vestibular (“staggers”)—vertigo, hearing loss, tinnitus, and disequilibrium

Answer 16

Type II: “serious” DCS

Question 17

What TYPE of Decompression Sickness (DCS) presents with

Symptoms of “staggers”, “chokes” and STROKE SSx occuring on ascent or immediately upon surfacing

Answer 17

Type III: combination of DCS and arterial gas embolism

Question 18

The San Diego Diving and Hyperbaric Organizations criteria for arterial gas embolism uses a cut point of _____ points for the diagnosis of arterial gas embolism

Answer 18

≥2

Question 19

• Initial tingling to numbness then localized edema, erythema, cyanosis, plaques, nodules, and, in rare cases, ulcerations, vesicles, and bullae, 12 to 24 hours after exposure
• With pruritus and burning paresthesias
• Tender blue nodules on rewarming.
• long-term intermittent exposure to damp nonfreezing ambient temperatures
• most commonly affecting feet (toes), hands, ears, and lower legs

Answer 19

CHILBLAINS or PERNIO

Question 20

• mild degrees of necrosis of subcutaneous fat tissue that develops during prolonged exposure to temperatures just above freezing
• observed in children exposed to topical cold objects and on the thighs and buttocks of young women involved in equestrian activities

Answer 20

PANNICULITIS

Question 21

hypersensitivity to cold air or water, which in rare cases may lead to anaphylaxis

Young adults and children and those with atopy are most commonly affected

Answer 21

COLD URTICARIA

Question 22

Classify the frostbite injury:

Numbness, central pallor with surrounding erythema and edema, desquamation, dysesthesia

Answer 22

First degree

Question 23

Classify the frostbite injury:

partial skin freezing, erythema, mild edema, lack of blisters, and occasional skin desquamation several days later. The patient may complain of stinging and burning, followed by throbbing

Answer 23

First degree

Question 24

Classify the frostbite injury:

Blisters of the skin with surrounding edema and erythema

Answer 24

Second degree

Question 25

Classify the frostbite injury:

• full-thickness skin freezing, formation of substantial edema over 3 to 4 hours, erythema, and formation of clear blisters filled with fluid rich in thromboxane and prostaglandins
• blisters form within 6 to 24 hours, extend to the end of the digit, and usually desquamate and form hard black eschars over several days.
• numbness, followed by aching and throbbing.

Answer 25

Second degree

Question 26

Classify the frostbite injury:

Tissue loss involving the entire thickness of the skin; hemorrhagic blisters

Answer 26

Third degree

Question 27

Classify the frostbite injury:

damage that extends into the subdermal plexus.

Hemorrhagic blisters with skin necrosis and a blue-gray discoloration

like a “block of wood,” with burning, throbbing, and shooting pains

Answer 27

Third degree

Question 28

Classify the frostbite injury:

The skin is mottled, with nonblanching cyanosis, and eventually forms a deep, dry, black, mummified eschar. Vesicles often present late, if at all, and may be small, bloody blebs

Answer 28

Fourth degree

Question 29

From the DROWNING Algorithm, when do you decide to discharge or admit patient? When do you decide to observe for 4-6 hours?

Answer 29

Question 30

• progressive neurologic deterioration or ataxia in an individual who has recently ascended to high altitude
• Headache, nausea, and vomiting are common antecedents
• characterized by altered mental status, ataxia, stupor, and progression to coma if untreated
• Focal neurologic signs such as third or sixth cranial nerve palsies.

Answer 30

HACE

HIGH-ALTITUDE CEREBRAL EDEMA

Question 31

Because early diagnosis is critical, _________ or __________
should raise the suspicion of early HAPE or HIGH-ALTITUDE PULMONARY EDEMA

Answer 31

decreased exercise performance
or
dry cough

Question 32

hallmark of HAPE or HIGH-ALTITUDE PULMONARY EDEMA

Answer 32

Progression of dyspnea with exertion to dyspnea at rest

Question 33

HAPE treatment of choice

Answer 33

Immediate descent

Question 34

Treatment of HACE

Answer 34

oxygen supplementation, descent, and steroid therapy

Descent is the highest priority
Oxygen 2–4 L/min or titrated to SaO2 >90%
Dexamethasone, 8 milligrams PO, IM, or IV, then 4 m illigrams every 6 h
Hyperbaric therapy if patient cannot descend

Question 35

Treatment for Periodic breathing/ insomnia

Answer 35

Acetazolamide, 62.5–125.0 milligrams PO at bedtime as needed

Question 36

High-altitude pulmonary edema treatment

Answer 36

Immediate descent or evacuation
Oxygen 4 L/min or titrated to SaO2 >90%
Nifedipine, 30 milligrams PO extended-release every 12 h, or tadalafil, 10 milligrams PO every 12 h if no oxygen or descent*
Hyperbaric therapy if patient cannot descend
Measures to minimize patient exertion and keep patient warm
Dexamethasone if cerebral signs present, 4 milligrams PO every 6 h

Question 37

Moderate/severe AMS treatment

Answer 37

Immediate descent for worsening symptoms
Low-flow oxygen if available
Acetazolamide, 250 milligrams PO twice a day, and/or dexamethasone, 4 milligrams PO every 6 h
Hyperbaric therapy

Question 38

Mild AMS treatment

Answer 38

No further ascent
Descent to lower altitude or acclimatization at same altitude
Acetazolamide, 125–250 milligrams PO twice a day, to speed acclimatization
Symptomatic treatment as necessary with analgesics and antiemetics

Question 39

syndrome characterized by headache along with some combination of nausea or vomiting, dizziness, fatigue, or sleep disturbance

Answer 39

AMS
ACUTE MOUNTAIN SICKNESS