Medical Education, Board Review, Questions

Board Review Questions: August 2018

PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from PEER, updated continually on its digital platform. Order PEER to prepare!

1. A 35-year-old woman presents following a syncopal event that occurred 1 hour earlier. She had chest discomfort, palpitations, shortness of breath, and a sense of gasping for air. Shortly before losing consciousness, she felt a tingling in her hands. There is no evidence of cardiac disease; she has a medical history of anxiety. What laboratory value and resultant physiologic response is associated with this phenomenon?
A. Hypercarbia, cerebral vasoconstriction
B. Hypercarbia, cerebral vasodilation
C. Hypocarbia, cerebral vasoconstriction
D. Hypocarbia, cerebral vasodilation

2. An elderly man presents with chest discomfort. His history is worrisome for ACS, but the examination is significant only for chronic medical issues. Vital signs are normal. The ECG demonstrates normal sinus rhythm with no ST-segment or T-wave abnormalities. Initial therapy is initiated, and laboratory tests are ordered. The patient remains stable, and the initial troponin level is normal. Which of the following is the correct approach to treatment, observation, and reassessment?
A. Intravenous heparin, oral clopidogrel, and oral aspirin with immediate exercise stress testing
B. Intravenous heparin, oral clopidogrel, and oral aspirin with serial troponin and 12-lead ECG sampling
C. Oral aspirin therapy with immediate exercise stress testing, with or without nuclear imaging
D. Oral aspirin therapy with serial troponin measurement and 12-lead ECG sampling

3. Which of the following treatments for acute asthma in the emergency department reduces the relapse rate?
A. Heliox
B. Long-acting beta2-adrenergic receptor agonists
C. Oral corticosteroids
D. Oxygen via nasal cannula

4. Which of the following is a clinical manifestation of opioid withdrawal?
A. Constipation
B. Delirium
C. Miosis
D. Piloerection

5. Which of the following statements about uterine trauma in pregnant patients is correct?
A. Cardiotocographic monitoring is unlikely to identify occult trauma
B. Pelvic fractures are associated with extremely high morbidity and mortality rates
C. Ultrasonography is the best diagnostic modality for uterine rupture
D. Uterine perforation occurs most commonly in the first trimester

Answers: 1. C; 2. D; 3. C; 4. D; 5. B

1. The correct answer is C, Hypocarbia, cerebral vasoconstriction.
Why is this the correct answer?
Psychiatric illnesses, most commonly major depressive disorder and generalized anxiety disorder, can be associated with symptoms of syncope. Hyperventilation as a result of these disorders causes a blowing off of carbon dioxide resulting in hypocarbia. This respiratory alkalosis leads to constriction of the cerebral blood vessels. The vasoconstriction can lead to lightheadedness with resultant syncope if the patient concurrently performs a Valsalva maneuver or has been standing for a prolonged period of time. The alkalosis can also result in constriction of peripheral blood vessels contributing to the tingling feeling in the hands and feet. A thorough medical workup for organic causes of the syncopal event should be initiated before diagnosing a psychiatric syncope.

Why are the other choices wrong?

  • Hyperventilation leads to hypocarbia, not hypercarbia. Hypercarbia occurs in respiratory acidosis from decreased volume or rate of breathing.
  • Hyperventilation leads to hypocarbia, not hypercarbia. But hypercarbia from respiratory acidosis can cause minimal cerebral vasodilation.
  • Hypocarbia from respiratory alkalosis is associated with cerebral vasoconstriction and decreased cerebral blood flow.

REFERENCES

  1. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:339-367.e4.
  2. Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:360-365.

2. The correct answer is D, Oral aspirin therapy with serial troponin measurement and 12-lead ECG sampling.
Why is this the correct answer?
Patients with suspected ACS and an entirely normal ECG who are hemodynamically stable have a very low rate of acute MI, ranging from 1% to 3%. Thus, management decisions should be based on the total presentation, considering all the features of the patient’s data, observing the patient’s response to treatment, and reassessing the clinical picture and risk factors. A patient who is stable, does not develop concerning issues during the emergency department stay, has a negative workup with normal serial troponins and ECGs, and who does not exhibit signs of worrisome alternative diagnoses can be safely discharged and referred to either a primary care physician or cardiologist for further evaluation. In this setting (stable patient with initially negative evaluation), oral aspirin is the most appropriate therapy.

Why are the other choices wrong?

  • In a stable patient with an initially negative evaluation who has remained hemodynamically stable during a period of observation and reassessment, administering antiplatelet and anticoagulant agents in the emergency department is excessive; of course, this statement does not apply to oral aspirin therapy. The early use of exercise stress testing (emphasis on “early”) likely is not the most appropriate evaluation strategy in a patient such as the one in the case who has a concerning but stable ACS presentation.
  • Again, the heparin and clopidogrel are not necessary given that the patient is stable. But monitoring with serial troponin measurements and 12-lead ECG sampling is appropriate for this nondiagnostic chest pain presentation.
  • Aspirin is one of the most appropriate initial therapies in suspected ACS; it has significant abilities to favorably affect mortality rates. But without serial troponin measurements and 12-lead ECG sampling, early exercise stress testing at this point in the patient’s care is not the most appropriate evaluation strategy for a concerning but stable ACS presentation.

REFERENCES

  1. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:997-1033.
  2. Mattu A, Brady WJ, et al (eds). Cardiovascular Emergencies. Dallas, TX: American College of Emergency Physicians Publishing; 2014:11-35.
  3. O’Connor RE, Al Ali AS, Brady WJ, et al. Part 9: Acute Coronary Syndromes—2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:s483-s500.

3. The correct answer is C, Oral corticosteroids.
Why is this the correct answer?
Several studies have demonstrated that the prompt use of corticosteroids in asthma patients in the emergency department can improve air flow, thus decreasing both relapse rate and hospital admission rate in both adults and children. The glucocorticoids decrease inflammation of the airways; the type of corticosteroid (short acting or long acting) and the mode (oral, inhaled, IM, IV) all seem to provide the positive response to treatment. Effects of corticosteroids can be seen as rapidly as 2 hours after administration, so administering them early in the emergency department course is important.

Why are the other choices wrong?

  • Heliox is a combined gas mixture (about 80% helium and 20% oxygen) used to lower effort in patients with critical bronchospasm due to the properties of the inert helium gas. There are no large studies that indicate whether this improves asthma outcomes, such as decreased relapse or intubation rates.
  • Long-acting beta2-adrenergic receptor agonists are not effective for acute asthma symptoms and have a black box warning against their use for acute symptoms. These medications are intended to be used in conjunction with inhaled corticosteroids for long-term control of symptoms. Short-acting beta2-adrenergic receptor agonists are the key to treatment of acute asthma in the emergency department. Providing repeated treatments by nebulizer or inhaler with a spacer has been shown to provide bronchodilation. Studies have shown that intravenous and subcutaneous short-acting beta2-agonists (epinephrine and terbutaline) do not provide any improvement in outcomes compared to inhaled beta2-adrenergic receptor agonists.
  • There have been no studies of the use of just oxygen without other treatment modalities to show that oxygen itself can decrease rate of relapse in acute asthma. Use of oxygen via nasal cannula is recommended to keep Sao2 greater than 90% in patients with severe asthma. Hypoxia has been shown to be a factor in death resulting from severe asthma, so oxygenation is important. In addition, the studies show that use of oxygen with nebulized beta2-adrenergic receptor agonists improves outcomes compared to the use of air for nebulization.

REFERENCES

  1. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:941-955.
  2. Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:468-475.
  3. Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014:423-429.

4. The correct answer is D, Piloerection.
Why is this the correct answer?
Opioid withdrawal is characterized by a constellation of clinical manifestations that can include abdominal pain, anxiety, diaphoresis, diarrhea, irritability, myalgias, mydriasis, piloerection (involuntary erection of the skin hairs [“gooseflesh”]), rhinorrhea, vomiting, and yawning. Although very uncomfortable, opioid withdrawal is not life-threatening nor is it characterized by altered level of consciousness.

Why are the other choices wrong?

  • Constipation is a common manifestation of opioid use, not withdrawal. Diarrhea occurs in withdrawal.
  • A significant altered level of consciousness, including delirium, is not expected in opioid withdrawal. Delirium should not be attributed to opioid withdrawal.
  • Miosis is a manifestation of opioid intoxication, not withdrawal. Mydriasis is often present in withdrawal.

REFERENCES

  1. Hoffman RS, Howland MA, Lewin NA, et al, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill; 2015:204.
  2. Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:1255.

5. The correct answer is B, Pelvic fractures are associated with extremely high morbidity and mortality rates.
Why is this the correct answer?
Pelvic fractures are associated with extremely high morbidity and mortality rates in pregnant patients as well as in fetuses. Bony fragments can cause uterine perforation, rupture, hematoma, and contusion. These conditions can lead to uterine irritability, hemodynamic compromise of the fetus, fetal injury, and placental abruption. The pelvic veins are also relatively dilated during pregnancy, leading to an increased volume of bleeding with pelvic fractures. Any trauma during pregnancy is also associated with a high rate of fetal distress and demise. 

Why are the other choices wrong?

  • Cardiotocographic monitoring is the most sensitive modality for identifying occult trauma to the uterus or to the fetus. A period of 4 to 6 hours of cardiotocographic monitoring is indicated after even the most minor trauma, either blunt or penetrating. Monitoring can identify subtle changes in fetal heart rate that might indicate fetal distress. In addition, monitoring can identify uterine irritability or early signs of placental abruption that can be missed with other diagnostic modalities.
  • Ultrasonography can be helpful in identifying uterine perforation, hematoma, or placental abruption but can miss more subtle injuries. A negative examination should prompt additional workup and monitoring.
  • Uterine perforation occurs most commonly during the third trimester when the uterus is relatively exposed. It can occur due to both blunt and penetrating trauma. During the first trimester, the uterus is small and relatively protected by the bony pelvis.

REFERENCES

  1. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:296-304.
  2. Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014:321-325.

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