EBEEM Part A - Preparation Materials

Sample Multiple Choice Questions

(revised September 2014)
Abdominal Pain

1. In a case of acute pancreatitis, which of the following statements is true?

 Alcohol is the most common cause.

 Measurement of serum Lipase level is preferred to Amylase level if available.
 About 15% of patients are at risk of developing acute pancreatitis within 30 days after ERCP.
 The use of prophylactic antibiotics is strongly recommended.
 Complications include renal artery or vein thrombosis.

Ref: Tintinalli 7th edition, Chapter 82

2. A 28 year old woman is brought to the ED with a history of lower abdominal pain, vaginal bleeding and
collapse. Ectopic pregnancy is suspected. Which of the following statements are true?

 A single Beta hCG can reliably distinguish between a normal and pathological pregnancy.
 A history of tubal surgery is a risk factor.
 No missed menses are reported in 15% of cases.
 A normal placenta is uncommon.
 Vaginal bleeding is present in 30% of cases.

Ref: Tintinalli 7th edition, Chapter 101

3. Which of the following statements is true when considering management of patients with acute severe
abdominal pain in the ED?

 Opioid analgesics will not obscure abdominal findings.

 Forced IV hydration can help relieve the pain of ureteric colic
 The presence or absence of femoral pulses is generally not helpful in the clinical diagnosis of AAA.
 Metoclopramide provides pain relief equivalent to narcotic analgesics in renal colic.
Though this answer is correct, we would not use it in the actual exam, because it is not yet an internationally
recognised guideline
 Use of a nasogastric tube is often unnecessary in the management of intestinal obstruction.

Ref: Tintinalli 7th edition, Chapter 74, 97, 86

4. Which of the following statements is true about elderly patients with abdominal pain?

 Mortality almost doubles if the diagnosis is incorrect at the time of admission in patients over 80 years of age.
 Clostridium Difficile is an anaerobic, gram positive bacillus which can cause debilitating diarrhoea.
 Oral Vancomycin is the first line therapy for diarrhea caused by Clostridium Difficile.
 Fever is a reliable marker for surgical disease.
 Acute Cholecystitis is the most common surgical entity with acute abdominal pain.

Ref: Tintinalli 7th edition, Chapter 74

5. Which of the following statements is true about children presenting with abdominal pain?

 Bilious vomiting in an infant is a true emergency.

 Perforation rates approach 90% in children under 4 years of age with appendicitis.
 Urinary tract infection is the most common cause of abdominal pain in children of all age groups.
 Air insufflation is preferred over barium enema to investigate Intussusception as a cause.
 The complete blood count is a useful screening test for undifferentiated abdominal pain.

Ref: Tintinalli 7th edition, Chapter 124, 126

6. The most common cause of uncomplicated urinary tract infection is:

 Pseudomonas Aeruginosa

 Klebsiella species

 Proteus Mirabilis

 Escherichia coli

 Chlamydia Trachomatis

Ref: Tintinalli 7th edition, Chapter 94

7. An eighty year old man presents with severe sudden onset of left flank pain which is radiating to his left groin.
His systolic BP is 80 mm of Hg and pulse is 130/min. A bedside ultrasound shows enlarged abdominal aorta.
What is the next best step in the management of this patient?

 Arrange an emergent CT scan to confirm the rupture of the aneurysm.

 Start vigorous active resuscitation with fluids and bloods to restore blood pressure to normal.
 Arrange urgent vascular surgical consult for operative repair.
 Withhold analgesia because it might mask the symptoms and cause worsening of hypotension.
 Give beta blockers to reduce perioperative mortality.

Ref: Tintinalli 7th edition, Chapter 63

8. A 20 year old drunk man has fallen down from the second floor of a building and landed on a concrete floor.
He is unconscious, hypotensive and tachycardic. He has no long bone fractures. There is no obvious bleeding.
Supine X-rays of his chest and pelvis are normal. What is the most probable cause for his hypotension?

 Neurogenic shock due to cervical spine fracture.

 Abdominal solid organ injury.
 Pneumothorax
 Cardiac contusion.
 Severe brain injury.

Ref: Tintinalli 7th edition, Chapter 260

9. The most common cause of rhabdomyolysis is:

 Trauma
 Intense physical activity
 Seizures
 Muscle diseases
 Alcohol and drug abuse

Ref: Tintinalli 7th edition, Chapter 92

10. The age group of children in which Intussusception is the most common cause of intestinal obstruction is:

 3 weeks to 3 months of age.

 3 months to 6 years of age.
 6 to 8 years of age.
 8 to 10 years of age.
 10 to 12 years of age.

Ref: Tintinalli 7th edition, Chapter 124

Altered Mental State

1. A 21 year old man is brought unconscious to the ED by his friends. They state that the patient had an episode of
seizures lasting for 2 minutes. They mentioned that he drank a lot of alcohol and two energy drinks. Which of the
following statements is true:

 Hypoglycemia is the most common metabolic cause of seizure activity

 Phenytoin is recommended as first-line therapy for adults with seizure activity
 Diazepam may be given rectally, endotracheally or intraosseously, if intravenous access cannot be achieved
 Lorazepam is inappropriate for the initial management of status epilepticus
 Use of maximal doses of first-line agents for adults with persistent seizure activity may require intubation and
ventilatory support

Comment: in the actual exam the question would be worded as follows: in a patient coming to the ED with a
seizure, which of the following statements is true?

Ref: Rosen's Emergency Medicine, 7th edition, Chapter 15

2. A 56-year-old man suffered a blunt head trauma 12 hours ago. He presents to the ED for headache. In the triage
area he develops a generalized seizure. Which of the following statements is true:

 Immediate post-traumatic seizures occur within 24 hours of injury

 Immediate and early post-traumatic seizures are more common in adults than in children
 Children are more likely than adults to present in status epilepticus in the immediate or early post-traumatic
phase
 Early post-traumatic seizures occur within 1 week of injury
 Epidural, subdural, intracerebral and traumatic subarachnoid hemorrhages can all be acutely ictogenic

Ref: Rosen's Emergency Medicine, 7th edition, Chapter 100

3. Regarding altered mental state, which of the following statements is true:

 Altered mental status and focal neurologic findings may be manifestations of air embolism
 The symptoms and signs of disequilibrium syndrome may include altered mental status and coma
 Altered mental status, metabolic acidosis and decreased urine output are findings that help define significant
hypoperfusion
 Hypotension and altered mental status can frequently be observed following ingestion of cyanide
 Altered mental status, seizures and coma may frequently occur during or immediately after peritoneal
dialysis.
4. A 48-year-old male is brought to the ED by an ambulance. He is confused, and presents with ophthalmoplegia
and nystagmus and smells of alcohol. Which of the following statements is true?

 Wernicke's encephalopathy is a frequent complication of chronic alcoholism

 Alcoholics with altered mental status should receive thiamine (100 mg IV) and either a rapid blood glucose
determination or empirical dextrose (25 g IV)
 Oculomotor abnormalities is one of the diagnostic criteria for Wernicke's encephalopathy
 Patients with Wernicke's syndrome require admission and aggressive thiamine and magnesium repletion
 Korsakoff syndrome occurs more frequent in younger alcoholics

Ref: Rosen's Emergency Medicine, 7th edition, Chapter 183

5. Which of the following statements related to non-convulsive status epilepticus is true?

 The patient is either comatose or confused

 EEG plays a small role in the diagnosis of non-convulsive status epilepticus
 A very short post-ictal period is highly suggestive of non-convulsive status epilepticus
 Non-covulsive status epilepticus is associated with sleep deprivation and electrolyte abnormalities
 Subtle motor signs such as twitching, blinking and eye deviation are suggestive findings

Ref: Tintinalli 7th edition, Chapter 165

6. Which of the following statements is true regarding the herniation syndrome?

 In uncal herniation syndrome, the medial temporal lobe shifts to compress the lower brainstem
 Central herniation syndrome is characterized by progressive loss of consciousness, loss of brainstem reflexes,
decorticate posturing and irregular respirations
 The main clinical manifestation of central herniation syndrome is general seizures
 Vascular compression due to local cerebral edema or local increased intracranial pressure must not be
considered as an underlying mechanism for the central herniation syndrome
 In central herniation syndrome the ipsilateral pupil is hyperactive as the third cranial nerve is compressed by
the medial lobe

Ref: Tintinalli 7th edition, Chapter 162

7. Which of the following is true regarding delirium?

 the onset is typically sudden

 is rarely associated with hallucinations
 Symptoms may be intermittent within a brief time span
 The Glasgow Coma Scale can be used for detection
 hyperglycemia is one of the common metabolic causes in elderly patients

Ref: Tintinalli 7th edition, Chapter 162

8. Which of the following statements regarding altered mental status associated with subarachnoid hemorrhage
(SAH) is true?

 According to the Hunt and Hess scale, patients with altered mental status ranging from stupor to deep coma
are ranked as grade IV and V
 Most patients with SAH have an altered mental status with focal neurologic signs at the onset of symptoms
 All patients in whom headache is the first symptom of SAH will progress to deep coma
 Treatment with antifibrinolytics has been proven to improve the outcome of the patients with altered mental
status and SAH
 Anti-convulsants are routinely used as prophylactic drugs in patients with altered mental status associated
with SAH

Comment: though the question is correct, in the actual exam the statement would read, “the Hunt and Hess scale is
used to classify the severity of a non-traumatic subarachnoid hemorrhage”

Ref: Rosen's 7th edition, Chapter 101

9. Which of the following represents an etiologic factor for altered mental status and coma due to decreased
cerebral blood flow?

 Creutzfeldt - Jakob disease

 Malignant hyperthermia
 Severe anemia
 Septic shock
 Subdural hematoma

Ref: Rosen's Emergency Medicine, 7th edition, Chapter 14

10. Which of the following is true regarding toxic-metabolic coma?

 Cerebral edema is an important clinical indicator

 Is due to focal CNS dysfunction in a specific region of the brain
 Absence of extraocular movements supports the diagnosis
 Muscle stretch reflexes are asymmetric
 Typically the pupils are small but reactive

Ref: Tintinalli 7th edition, Chapter 162

Pulmonary Emergencies

1. A 23 year old man presents with a coma and bradypnoea. BGA on room air shows: pH 7.16 pO2 48 mmHg
HCO3 28 mmol/L. Which of the following statements are correct?

 This is acute hypoxemic respiratory failure (type I)

 This is acute hypercapnic respiratory failure (type II)
 This is acute on chronic hypercapnic respiratory failure (type II)
 This is aspiration pneumonia
 This is pump failure due to respiratory drive suppression

Ref: Tintinalli 7th edition, Chapter 20, 65

2. A 79 year old woman presents with acute dyspnoea. BGA while breathing O2 10 L/min via reservoir mask is:
pH 7.51 pCO2 31mmHg pO2 57 mmHg HCO3 23 Which of the following statements are true?

 The BGA shows acute respiratory acidosis

 The BGA shows acute respiratory alcalosis
 The BGA shows remarkable impairment of gas exchange (lung failure)
 The BGA shows chronic respiratory alcalosis
 The BGA shows hyperventilation

Ref: Tintinalli 7th edition, Chapter 20, 65

3. A 54 year old man presents with dyspnoea and productive cough since 2 days. BGA shows: pH 7.21 pO2 49
HCO3 36. Which of the following statements is correct?

 This is acute hypoxemic respiratory failure (type I)

 This is hypercapnic respiratory failure (type II)
 This is acute on chronic hypercapnic respiratory failure (type II)
 This is chronic hypercapnic respiratory failure (type II)
 This is an acute metobolic and respiratory acidosis

Ref: Tintinalli 7th edition, Chapter 20, 65

4. A 83 year old man presents with acute dyspnoea, bilateral rales and CXR congestion; SpO2 is 84% with
reservoir mask at 12 L/min. Ten minute after non-invasive PEEP application with FiO2 0.6, SpO2 rises from
84% to 93%. The oxygenation improvement with PEEP application is most likely due to:

 Bronchodilatation
 Alveolar recruitment
 Afterload increase
 Afterload decrease
 Increaesed FiO2

Ref: Tintinalli 7th edition, Chapter 20, 65

5. Two boys have been admitted contemporarily to your ED. BGA has been performed before you see them.
Maurice’s BGA shows pO2 of 82mmHg and pCO2 of 24; Mark's gas values are: pO2 69 and pCO2 34. Who are
you seeing first?

 No difference in severity
 Mark, because pO2 is lower
 Mark, because pCO2 is higher
 Mark, because pO2 is lower and pCO2 is higher
 I want to know FiO2 first

Ref: Tintinalli 7th edition, Chapter 20, 65, 119

6. Bonny and Clyde are admitted to your ED with pneumonia. While breathing room air, Bonny’s BGA shows pH
7.42 pCO2 34 pO2 68; Clyde’s shows 7.54 pCO2 24 pO2 68. Who’s more severe?

 Bonny, because she’s hypoventilating

 No difference in severity, since pO2 is the same
 Bonny, because her pH is lower
 Clyde, because he’s hyperventilating
 No difference in severity, since pO2/FiO2 ratio is the same

Ref: Tintinalli 7th edition, Chapter 20, 65

Trauma

1. FAST examination in a patient with haemorrhagic shock can:

 Quantify blood loss

 Rule out retroperitoneal injury
 Identify the specific site of injury in 50% of cases
 Provide information about the volume status of the patient
 Detect as little as 50ml of fluid in the subphrenic space, subhepatic space and pelvis

Ref: Tintinalli’s Emergency Medicine: Chapter e299.4

Rationale:

 FAST examination has a sensitivity of 90%, specificity of 99%, and accuracy of 99%.
 Equally sensitive, specific, and accurate for both blunt and penetrating torso trauma.
 Identification and localization of significant hemorrhage in penetrating trauma patients would allow
physicians “to prioritize resources for resuscitation and evaluation.”
 Echocardiography remains the gold standard diagnostic procedure for detecting pericardial effusions.
 Accurate diagnostic screening test for AAA
2. A 74 year old man with a history of severe dementia is brought to the Emergency Department with full neck
immobilisation following a fall in his bathroom. He has several bruises on his face and is confused. His cervical
spine can be cleared if:

 He denies neck pain when the cervical collar is removed

 He denies neck pain when asked to turn his head laterally both ways
 CT scan of his cervical spine is normal
 His CT scan, MRI and plain flexion/extension films are all normal and mental status is back to baseline
 Re-examination done after waiting for the confusion to clear shows no spine tenderness

Ref: Tintinalli’s Emergency Medicine, Chapters 252, 255; Canadian cervical spine rule; NEXUS criteria

Rationale:

 Patients with head or neck trauma with GCS<15 should undergo C spine imaging
 C spine imaging is NOT useful in patients who are alert, orientated, and have no neck or back pain or
tenderness
 2 Clinical decision rules – target low-risk trauma patients to avoid unnecessary radiography; both are
intended for alert, stable adult trauma patients who have NO neurological deficits.
 NEXUS: 99.6% sensitive for detecting clinically significant c spine injuries, but only 12.9% specific;
 Canadian C spine rule for radiography: for alert, stable trauma patients to reduce practice variation and
inefficiency in the ED use of C spine radiography; 100% sensitive and 42.5% specific for identifying patients
with clinically important c spine injuries.
3. A 16 year old boy was punched in the face during a fight. He lost consciousness briefly following the assault.

During your assessment, you would expect to find:

 Fracture of the left orbital floor

 Reduced visual acuity in the left eye
 Left infraorbital hypoaesthesia
 Loss of lacrimation from the left eye
 Bell’s phenomenon

Ref: Tintinalli’s Emergency Medicine, Chapter 256

Rationale:

X RAY findings:
- Tear drop sign
- Fluid level in maxillary sinus
- Opacification of maxillary sinu
Management of inferior orbital wall fractures
 Antibiotics
 Decongestants
 Avoid nose-blowing
 Ophthalmology referral / consultation
4. A 5 year old child fell while playing in the playground 2 hours ago and hit his head. According to recent NICE
guidelines, the child should be admitted for observation in hospital but would not need a CT scan of the head if:

 GCS is 14 on arrival in the Emergency Department

 The child is drowsy but has no other symptoms
 The child has vomited twice since the injury
 There is anterograde amnesia for 2-3 minutes
 The child has had a seizure post injury, lasting 30 seconds

Ref: NICE guidelines 2014 http://www.nice.org.uk/guidance

Rationale:

1.4.10 For children who have sustained a head injury and have more than 1 of the following risk factors (and none of
those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified:
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle
occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object).
- Amnesia (antegrade or retrograde) lasting more than 5 minutes

A provisional written radiology report should be made available within 1 hour of the scan being performed.

1.4.11 Children who have sustained a head injury and have only 1 of the risk factors in recommendation 1.4.10 (and
none of those in recommendation 1.4.9) should be observed for a minimum of 4 hours after the head injury. If during
observation any of the risk factors below are identified, perform a CT head scan within 1 hour:

- GCS less than 15.

- Further vomiting.
- A further episode of abnormal drowsiness.

A provisional written radiology report should be made available within 1 hour of the scan being performed. If none
of these risk factors occur during observation, use clinical judgement to determine whether a longer period of
observation is needed.
5. An 85 year old woman presents to the Emergency Department with painful swelling and deformity of her right arm
following a fall onto her outstretched right hand. Her X ray appears below:

 Radial nerve palsy may occur in 10-20% of cases

 Sensation over the first web space may be absent
 Immediate radial nerve paralysis is a poor prognostic sign for full nerve recovery
 Surgery is usually required if there is concomitant axillary nerve neuropraxia
 Mild radial nerve neuropraxia recovers within 2-8 weeks after injury

Ref: Tintinalli’s Emergency Medicine, Chapter 269

Rationale:

FRACTURES OF THE MID-SHAFT OF THE HUMERUS:

Management of fracture:
 Plaster U slab
 Hanging cast
 Surgery (internal / external fixation)

Complications: non-union; radial nerve palsy; injury to brachial artery or vein; injury to ulnar / median nerves
Evidence of radial nerve palsy: wrist drop, sensory impairment on dorsal aspect of first web space
Most nerve injuries recover with conservative Rx only
Radial nerve palsy + open fracture = surgical exploration
6. A 54 year old man hit his chest on the steering wheel during a rapid deceleration road traffic accident. His
lateral CXR is shown below:

 This injury is complicated by arrhythmias in a third of cases

 Most of these injuries require open fixation
 Death usually occurs because of uncontrolled bleeding into the
thoracic cavity
 Shortness of breath usually indicates associated cardiopulmonary
contusion
 The patient will require cardiology follow up even if ECG is normal

Ref: Tintinalli’s Emergency Medicine, Chapter 258

Rationale:

STERNAL FRACTURES:

 Diagnosed: clinical (localised pain and tenderness), lateral CXR, CT scan, bedside ultrasound
 60-90% are due to mva
 Only 1.5% incidence of cardiac dysrhythmias after mva
 Mortality Rate < 1% if isolated injury
 Recent recommendations: patients with sternal fractures and normal vital signs + initial normal ECG, should
have a repeat ECG in 6 hours and if unchanged, require no further workup for cardiac injury.
7. A 4 year old boy fell off a bunk bed about 1.5 metres high and has been complaining of paraesthesiae in both
upper limbs since then. A cervical spine X ray is taken and appears normal.

 About 90% of children with spinal cord injuries have normal cervical spine x rays
 The neurological symptoms may be due to a ligamentous or disc injury
 The cervical spine need not be immobilised unless the child develops limb weakness
 The child may be discharged home if the cervical spine x ray is confirmed to be normal by a radiologist
 There is a 50% chance of requiring spinal surgery within the next 6 months

Ref: Tintinalli’s Emergency Medicine, chapter 251; NICE Head Injury guidelines, 2014

Rationale:

C SPINE INJURIES IN CHILDREN

See: https://www.nice.org.uk/guidance/cg176/resources/cg176-head-injury-imaging-algorithm2

Initial neurologic status is the most important factor in prognosis

NEXOS and Canadian decision rules – not applicable for children

Initial imaging: plain x rays, followed by CT scan if there is any doubt

If head CT is also planned, it is acceptable to do CT of the C spine without plain imaging first

SCIWORA – Spinal Cord Injury Without Radiographic Abnormality: occurs in up to 66% of spinal cord injuries
in children. If this diagnosis is considered, the child should be admitted to hospital and an early neurosurgical
consultation obtained.
8. A 26 year old woman who is 28 weeks pregnant is hit by a passing car and suffers multiple injuries. The
following statements are true EXCEPT:

 She should be given supplementary oxygen

 There should be a low threshold for endotracheal intubation
 IV fluids should be started early
 The patient should be transported on a stretcher tilted 30° towards the right side if supine
 The patient should be transferred to a higher level trauma hospital

Ref: Tintinalli’s Emergency Medicine, Chapter 253

Rationale:

TRAUMA IN PREGNANCY:

 Associated with increased risk of preterm labour, abruptio placentae, foetomaternal haemorrhage,
pregnancy loss
 Relevant physiological changes in pregnancy:
 Relative hypervolaemic state: patient may lose 30-35% of circulating blood volume before showing
hypotension or clinical signs of shock
 Relative tachycardia; relative hypotension
 Supine hypotension syndrome: after 18-20 weeks of gestation – venous return and cardiac output are
diminished by compression of the maternal IVC in the supine position
 Increased tendency to severe retroperitoneal haemorrhage
 Diaphragm becomes elevated

MANAGEMENT OF INJURED PREGNANT PATIENTS:
 Initial efforts must be directed towards adequate resuscitation of the mother, before evaluation of the
foetus
 Reduced ability to compensate for hypoxia – give supplemental oxygen
 Low threshold for early ETT, NGT and IV fluids
 If transported supine, place a wedge under the right hip area, tilting the patient 30° towards the left side,
OR manually displace the uterus towards the left side.
 Early consultation with surgeon and obstetrician
 Imaging – as for non-pregnant patients
 Start foetal monitoring asap and continue for at least 4-6 hours
 Low threshold for admission to hospital
9. A 35 year old man arrives at the ED resuscitation room about 1 hour after being stabbed in the abdomen. He
appears pale and clammy, HR is 120/minute and BP is 70/40. Your immediate management includes:

 2.5 litres of 0.9% Sodium Chloride fluid challenge

 2 litres of gelofusine using a pressure cuff
 O Negative blood to aim for a Hb level of 12 g/dl
 Tranexemic acid 1g over 10 minutes followed by TXA infusion of 1g over 8 hours
 Recombinant Factor VIIa 10 μg/kg i.v.

Ref: ABC of Major Trauma (BMJ) 4th edition, 2013

Rationale:

POLYTRAUMA

After haemorrhage, the systolic blood pressure of healthy adults may not decrease until 30–40% of their blood
volume has been lost.

Stop the bleeding as rapidly as possible.

Blood will be required rapidly if the patient is exsanguinating.

In the severely injured patient, maintain a haemoglobin concentration in the range 8–10 g/dL depending on the
specific circumstances and the patient's known co-morbidity.

Warm all fluids: hypothermia increases mortality.

In massive haemorrhage, give fresh frozen plasma and platelets early.
10. A 28 year old man’s right leg was pinned between the bumper of his car and his garage wall for about 45
minutes about 8 hours ago. He is complaining of severe pain in the lower half of his right leg anteriorly. On
examination his right lower leg feels slightly more tense to palpation than his left leg, and there is some bruising.
Your provisional diagnosis of compartment syndrome is supported by:

 Skin on the right leg feels warmer than on the left

 Linear fractures of the tibia and fibula are noted when an x ray is taken
 Passive muscle stretch relieves the pain slightly
 Elevating the right leg worsens the pain significantly
 Bluish discoloration of the whole of the right leg

Ref: Tintinalli’s Emergency Medicine, Chapter 275

Rationale:

COMPARTMENT SYNDROME

 40% of c s in the LL occur at the level of the tibia and fibula

 Prolonged elevation of ti
 Normal pressure within a compartment is <10 mm Hg; tissue pressures > 30-50 mm Hg are considered
toxic if left untreated for several hours
 HIGH INDEX OF CLINICAL SUSPICION REQUIRED
 Can develop up to 48 hours after an event
 Initial complaint is of severe pain, sometimes not even relieved with opioids

 Nerve dysfunction within the compartment: burning or dysasethesia in the sensory distribution of that
nerve
 Classical presentation: 5 P’s – Pain, Paraesthesiae, Pallor, Pulselessness, Poikilothermia
 Serum CPK and myoglobin ↑, myoglobinuria
 Rx = surgical fasciotomy
 Permanent damage if > 8 hours of ischaemia
 impairment unlikely
Pain Management, Analgesia & Sedation

1. Which of the following statements is TRUE regarding pain management in the ED?

 Acute pain is present in 60% of the patients presenting to the ED

 Patient’s perception of pain is the only valid perception
 Fear of inducing opioid addiction contributes to inadequate analgesia
 Gender and age of the patient do not influence analgesia provision
 The proper use of opioids requires consideration of side effects, initial dose and frequency of
administration

Ref: Tintinalli’s Emergency Medicine, Chapter 38

2. Which of the following statements is TRUE?

 The anterior horn of the spinal cord integrates and modulates pain and other sensory stimuli
 Euphoria, miosis and urinary retention are due to opioid µ1receptor stimulation
 NSAID’s safely can be used in adults and children for mild to moderate pain
 Children require more opioids than adults
 0,1 mg fentanyl IV is equipotent to 0,2 mg fentanyl trans mucosal

Ref: Tintinalli’s Emergency Medicine, Chapter 38

3. Which of the following statements is FALSE?

 Lidocaïne is an ester
 Midazolam is preferred as analgesic agent in children because it is short acting
 Radial nerve blocks provide anaesthesia to the ventral half of hand
 A femoral nerve block is performed by infiltrating a local anaesthetic medial to the femoral artery
 Anxiolytics should not be combined with narcotics due to the increased risk of respiratory depression

Rationale:

FALSE - lidocaine is an amide

FALSE - midazolam is a benzodiazepine and a choice agent for anxiolysis but not an analgesic
FALSE - radial nerve block provides analgesia tot the dorsal lateral half of the hand and the dorsal part of the thumb
FALSE - the femoral nerve is positioned lateral of the artery
FALSE - acute pain is usually accompanied by anxiety and feelings of loss of control. Anxiolytics should be
considered if pain persists
4. Which of the following statements is TRUE?

 Lidocaine may cause methemoglobemia

 Naloxone will reverse the effects of diazepam
 The frequency of a pneumothorax related to an intercostal block is 8%
 The three-in-one block offers analgesia in patients with hip fractures
 Minimal sedation is characterized by anxiolysis with reduced consciousness

Reference and rationale:

TRUE - Tintinalli’s Emergency Medicine, Chapter 201 p 1327

FALSE - Naloxone is an opioid antidote, the correct antidote is flumazenil. Tintinalli’s Emergency Medicine,
Chapter 201 p 1218
TRUE - Tintinalli’s Emergency Medicine, Chapter 41, p 282
TRUE - Tintinalli’s Emergency Medicine, Chapter 41
FALSE - Tintinalli’s Emergency Medicine, Chapter 41, p 284

5. Which of the following statements is TRUE regarding procedural sedation?

 In conscious sedation the patient can maintain the airway

 Moderate sedation is used for reduction dislocations
 Procedural sedation requires at least 2 physicians
 Oxygen saturation should be monitored continuously during the procedure
 Supplemental oxygen delivery can delay recognition of hypoventilation

Ref: Tintinalli’s Emergency Medicine, Chapter 41

6. A 3 year old child needs procedural sedation for a complicated suture. The most appropriate action is:

 Minimal preparation. Only oxygen saturation measurement required.

 A fastening period of at least 4 hours is mandatory before performing the procedure
 Propofol is the preferred analgesic
 Ketamine at doses < 1 mg/kg has analgesic and sedative effects
 Ketamine/propofol is a good choice because it’s use is safe and effective

Ref: Tintinalli’s Emergency Medicine, Chapter 39 + 41

7. A 80 year old patient with a hip fracture needs a femoral block. Which of the following is correct about this
procedure?

 Trendelenburg positioning is advised

 Inject after resistance is felt
 Optimal analgesia is obtained 2 minutes after injection
 20 ml lidocaine should be injected at the inguinal ligament lateral of the femoral artery
 Hypotension is a common complication after femoral nerve block

Ref: Tintinalli’s Emergency Medicine, Chapter 41

8. What is the most appropriate analgesic for an older woman with mild pain due to an ankle distortion with a
history of atrial fibrillation on warfarin:

 Morphine 10 mg PO 3 x dd
 Ibuprofen 800 mg PO 2x dd
 Acetaminophen 500 mg PO 4 x dd
 Diclofenac 50 mg IV 3 x dd
 Tramadol 50 mg PO 4 x dd

Ref: Tintinalli’s Emergency Medicine, Chapter 41

9. A 20 year old male has received analgesia for abdominal complaints. What is the endpoint of your pain
management?

 Patient indicates that the pain relief is ok

 The patient looks satisfied
 Normal blood pressure and arterial pulse
 The patient sleeps
 Pain scoring has reduced by 3 points

Ref: Tintinalli’s Emergency Medicine, Chapter 41

10. Which of the following statements is correct?

 Propofol rarely causes hypotension

 Acetaminophen is contra-indicated in patients with liver disease
 Ketamine may cause bronchospasm
 Morphine gives immediate pain relief
 Ethomidate causes hypotension
Ref: Tintinalli’s Emergency Medicine, Chapter 41
Obstetrics & Gynecology

1. A 22-year-old female presents to the ED with lower abdominal pain. She admits to having multiple sex
partners. On examination she is systemically unwell, presenting with a temperature of 38.6°C and
tachycardia of 105/min. The rest of her vital signs are normal. Vaginal examination confirms bilateral
adnexal tenderness as well as cervical motion tenderness. Which of the following statements is true:

 Best practice would be to await cervical swab results before commencing antibiotic treatment

 Amoxycillin+clavulanate 500 + 125 mg orally bd plus doxycycline 100 mg bd

orally is an appropriate antibiotic regimen in this scenario
 Current recommendations for the duration of antibiotic treatment in sexually acquired PID is
a 14-day treatment course
 Azithromycin 1 g orally given as a single dose followed by a course of doxycycline 100 mg
bd will be a effective treatment of Chlamydia
 HIV-testing is recommended

Ref: Emergency Medicine Manual, 6th edition, Ma, Cline, Tintinalli, Chapter 63
Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 126

2. Regarding drug use in pregnancy and lactation, which ONE of the following is the MOST
appropriate?

 The combination of paracetamol and ibuprofen can be used for migraine in a female of 18
weeks’ gestation
 The use of gentamicin is regarded as safe in the treatment of pyelonephritis in a female of 22
weeks’ gestation
 Metronidazole 2 g orally as a single dose for the treatment of symptomatic trichomonas is
contraindicated in pregnancy
 Oxycodone should not be given for acute pain relief in a breastfeeding mother
 LABA (long acting β2-agonists) for asthma treatment should be avoided during pregnancy

Ref: Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 118
www.medscape.com, Drugs and Diseases
 3. A 24-year-old female presents to the ED with blurred vision and slight headache. She is 26
weeks pregnant. Her BP is 150/100 mmHg and a urine dipstix shows 1+ protein. Which of the
following statements is TRUE?

 She requires conservative management with admission for monitoring

 She is at low risk of developing eclampsia as her BP is not high enough
 She requires immediate lowering of her BP with intravenous hydralazine
 Administration of magnesium sulphate will reduce the rate of development of eclampsia by at
least 50%
 The antidote for magnesium sulphate is Ca-gluconate 1g iv

Ref: Emergency Medicine Manual, 6th edition, Ma, Cline, Tintinalli, Chapter 60
Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 121

4. Regarding radiation exposure for probable PE in a 20 year old pregnant woman (3rd
trimester), which of the following statements is TRUE?

 A V/Q scan has a high negative predictive value

 A V/Q scan has a low sensitivity for small peripheral PE
 A V/Q scan has a higher radiation dose to the fetus than a CTPA
 A CTPA has the advantage of identifying other pathology
 The cancer risk is 1:620 for CTPA

Refs: Academic Life in Emergency Medicine, PV Cards, Cancer Risk from CT Smith-Bindman, R
et al, Arch Intern Med. 2009, 169(22), 2078-86.
Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 11

5. Regarding perimortem c-section after you have started CPR, which of the following is MOST
appropriate before performing this procedure?

 You have to displace the uterus

 You have six minutes to perform the procedure
 You have to transport the patient to theatre
 You have to assess if the fetus is viable
 You have to secure the airway

Ref: Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 11
Oxford Handbook of Emergency Medicine, 3rd edition, Chapter 13
 Shock

1. A 22-year-old man presents to the emergency department complaining of acute shortness of breath after being
kicked in the side. Vital signs show a blood pressure of 88/54 mm Hg, pulse 120 bpm, and respirations of 32/min. He
is afebrile. Physical exam reveals tracheal deviation toward the left and diminished breath sounds on the right.
Oxygen saturation by pulse oximetry is 95%. Which of the following additional investigations is indicated next?

 V/Q scanning
 Arterial blood gas
 Venous doppler study
 Chest radiography
 None of the above

Refs: Emergency Medicine Manual, 6th edition, Ma, Cline, Tintinalli, Chapter 165
Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 78
Oxford Handbook of Emergency Medicine, 3rd edition, Chapter 8

2. Assessment of the cardiovascular system in the paediatric trauma patient, which of the following clinical features is
not always suggestive of shock?

 Blood pressure
 Urine output
 Level of consciousness
 Peripheral extremities
 Capillary refill

Ref: Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 23

3. Which of the following haemodynamic resuscitation end points in shock is TRUE?

 Cardiac output 5.0 L/min

 Coronary perfusion pressure 50 mmHg
 Heart rate 110/min
 Lactate < 1mg/L
 CVP 8-12 mmHg

Ref: Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 4
4. Regarding the use of vasoactive agents in shock, which of the following statements is TRUE?

 Noradrenalin is a potent α–agonist with significant activity at β1-receptors and minimal or nor activity at β2-
receptors
 Metaraminol can cause reflex bradycardia and increased left ventricular afterload, which may be harmful in
patients with cardiogenic shock
 Isoprenalin is a non-selective β–agonist that causes peripheral vasodilation with subsequent fall in diastolic
and mean arterial blood pressure
 Dopamine at doses of 5-10 μg/kg/min predominantly acts on α–receptors with a profile similar to
noradrenalin
 Noradrenalin is preferred over adrenalin in patients with septic shock due to its proven mortality benefit

Ref: Emergency Medicine Clinical Essentials, 2nd edition, Adams et al, Chapter 4