Questions 09/20/2012

Thoracic and Environmental

Question 1
You are preparing to intubate an obese patient
(body weight 127 kg) with a history of sleep
apnea. What would be the approximate
desaturation time (SaO2 < 90%) for this patient
after paralysis if he was fully preoxygenated with
an FiO2 of 1:
a) 3 minutes
b) 5 minutes
c) 7 minutes
d) 9 minutes
e) 11 minutes

Answer 1
Preoxygenation
100% oxygen for 3 minutes of normal
tidal volume in healthy adult results in
8 minutes before desaturation to less
than 90%
Time to desaturation less in children,
obese adults, late-term pregnancy
women, and patients with significant
comorbidity

Answer 1

Question 2
You are managing a trauma patient with a
flail chest who is in respiratory distress.
Indications for mechanical ventilation
would include:
a) Respiratory rate > 25/min
b) Respiratory rate < 12/min
c) PaO2 < 70 mm Hg at FiO2 > 0.5
d) PaCO2 > 55 Hg at FiO2 > 0.5
e) Alveolar-arterial oxygen gradient > 350

Answer 2
Flail chest
3 or more ribs fractured at 2 points
Indications for mechanical ventilation
Respiratory failure (RR >35/min or < 8/min, PaO2
< 60 mm Hg at FiO2 0.5; PaCO2 > 55 mm Hg at
FiO2 0.5, alveolar arterial oxygen gradient > 450)
Clinical evidence of severe shock
Associated head injury with lack of airway control
or need to ventilate
Severe associated injury requiring surgery

Question 3
What is the MOST common finding in a
patient with a brown recluse spider
bite?
a) Severe itching
b) Local tissue necrosis
c) Severe muscle cramps
d) Anaphylaxis

Answer 3
Brown recluse spider bite
Characterized by local necrosis
Treatment includes:
Local wound care
Consider dapsone (helpful for local effects) if
presentation within 48 hours.
Watch for methemoglobinemia and hemolysis in
patients with G6PD deficiency

Black widow spider bite characterized by

muscle cramping

Question 4
A 45-year-old male has been found to have a
pneumonia. In determining whether he meets
admission criteria to the hospital you calculate the
patients Pneumonia Severity Index score. Which of the
following co-morbid conditions contributes most to the
PSI score. with food allergies will outgrow their allergies
over time
a) Renal disease
b) Cerebrovascular disease
c) Congestive heart failure
d) Liver disease
e) Neoplastic disease

Answer 4

Question 5
A 32-year-old worker is brought by ambulance from a synthetic
fiber manufacturing plant complaining of weakness and
dizziness after being overcome by fumes from the recovery
tanks. Shortly after arrival, he becomes unconscious. You are
concerned about toxic exposure. As you remove the patients
clothing you note the smell of almonds. After intubation and
administration of 100% oxygen, you:
a) Crush a pearl of amyl nitrite and hold it in the intake valve of
the Ambu bag
b) Administer methylene blue
c) Begin chelation therapy
d) Consult hyperbarics
e) Consult nephrology for possible hemodialysis

Answer 5
Cyanide poisoning
Binds Fe3+ in cytochrome ultimately
preventing ATP formation
Antidotes
Cyanokit (Hydroxocobalomin 5 gm IV)
Binds cyanide forming cyanocobalamin (B12)

Cyanide Antidote Kit (sodium thiosulfate, sodium

nitrite, amyl nitrite)
Nitrites form hethemoglobin which binds cyanide
Sodium thiosulfate acts as sulfur donor to enzyme
responsible for conversion of cyanide to thiocyanate
which is renally excreted

Question 6
In which patient is an ED thoracotomy MOST indicated?
a) A 76-year-old male who was the unrestrained driver in a 70
mph motor vehicle crash and was found pulseless at the
scene
b) A 25-year-old female with a gunshot wound to the right chest
that upon arrival to the ED is found to have a blood pressure
of 40 mmHg by palpation and no breath sounds on the right
c) A 40-year-old male with a stab wound to the left chest who
lost all vital signs 3 minutes prior to arriving at the ED and
has received bilateral needle chest decompressions
d) A 27-year-old construction worker with an impaled fence post
in his abdomen, a blood pressure of 90/60 mm Hg, and fluid
in Morisons pouch revealed by ultrasound

Answer 6
Thoracotomy
Indications
Penetrating Traumatic Cardiac Arrest
Cardiac arrest at any point with initial signs of life in the
field
Blood pressure < 50 mm Hg systolic after fluid
resuscitation
Severe shock with clinical signs of cardiac tamponade

Blunt Trauma
Cardiac arrest in the emergency department

Miscellaneous
Suspected air embolus

Question 7
Choose the correct statement concerning treatment of
snakebites:
a) Snakebites should be treated prophylactically with an
antibiotic selected for its Gram-positive activity,
particularly against staphylococcal species
b) The amount of antivenin given is based on the severity of
the symptoms
c) The dose of antivenin given to children is weight based
d) Of the calculated dose of antivenin, 25-50% should be
infiltrated into the local wound of the bite and the rest
given intravenously
e) Copperhead bites always require antivenin administration

Answer 7
Snakebite
Elapidae = coral snakes
Death most commonly from respiratory
paralysis
Other symptoms include tremors, dysarthria,
diplopia, miosis, ptosis, dyspnea and seizures

Crotalidae = pit vipers (rattlesnakes,

cottonmouths, copperheads)
Crofab antivenom if symptomatic

Question 8
While scaling Mt. McKinley, a34-year-old triathlete develops
headache, anorexia, nausea, vomiting, and fatigue. The
base camp physician will know that:
a) Cerebral edema is a possible consequence secondary to
hypocapnia or hypoxia
b) These symptoms will likely resolve without treatment as
she ascends higher
c) This condition is best treated with acetazolamide
d) Prior physical conditioning should have been effective in
preventing this illness
e) Because of the estrogen-protective effect, this patient will
have less severe symptoms than her male counterpart

Answer 8
Acute Mountain Sickness
Incidence varies with rate of ascent
Mild cases usually self limited and do not
require treatment (discontinue ascent, rest)
Moderate cases administer acetazolamide,
aspirin, acetaminophen for headache;
prochlorperazine for nausea; supplemental
oxygen in available
Descend for persistent or severe cases (add
dexamethasone)

Question 9
In discharging patients treated in the ED for asthma, you
must remember that:
a) Airway inflammation and edema usually take 6-12
hours to resolve
b) Patients receiving systemic corticosteroids should
continue this medication for at least 10 days
c) The relapse rate of those discharged is less than 10%
d) It is not the responsibility of the emergency physician
to initiate controller medications
e) Those who require ED treatment are likely to have
less asthma management skills than the average
asthmatic patient

Answer 9
Asthma
Inflammation takes 3-4 days to
resolve
Steroids should not be prescribed for
more than 5 days
More than 10% of asthmatic patients
treated in the ED return with a
relapse

Question 10
A 5-month-old previously healthy male infant presents to
the ED with cough and dyspnea for 2 days and a
temperature of 38.4 C (101.1 F). There is no family history
of asthma. His respiratory rate is 48/min and he has
bilateral expiratory wheezing and subcostal retractions.
His oxygen saturation is 93 % on room air. Which of the
following is the most common cause of his illness?
a) Adenovirus
b) M. pneumoniae
c) Parainfluenza virus
d) RSV
e) Staphylococcus aureus

Answer 10
Bronchiolitis
Inflammation of the small airways in children less
than 2 years old
RSV most common cause, believed to be associated
in up to 70% of cases
Factors that mandate hospitalization include:
Age less than 3 months
Gestational age less than 34 weeks
Ill appearance
Hypoxemia (SaO2 95%)
Tachypnea (>70/min)
Significant atelectasis on chest xray

Answer 10
Mild

Moderate

Severe

Feeding

Normal

Less

Poor

SaO2 in room
air

95%

9294%

<92%

Respiratory
rate

< 60

60-70

> 70

Retractions

None/minimal

Intercostal

Substernal

Accessory
muscle use

None

None

Neck or
abdominal

Wheeze

None/minimal

Moderate
expiratory

Severe
inspiratory/exp
iratory

Air exchange

Goode, equal
BS

Localized,
decreased BS

Multiple areas
of decreased
breath sounds

Answer 10