Questions, Board Review

Board Review Questions: April 2020

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!

A 4-year-old girl is brought in by her parents because she has foul-smelling vaginal discharge mixed with blood. She has no history of recent fever or UTI. Detailed questioning of the patient and her parents eliminates concern for sexual abuse. What is the expected finding on vaginal examination?
A. Normal anatomy
B. Retained foreign body
C. Urethral prolapse
D. Vaginal neoplasm


2. Which of the following is an indication to use a factor Xa inhibitor?
A. Presence of a mechanical valve
B. Prevention of atrial fibrillation
C. Thrombolysis in ischemic stroke
D. Treatment of DVT


3. What is the most common cause of death from complications of a Bordetella pertussis infection?
A. Diaphragm rupture
B. Pneumonia
C. Pneumothorax
D. Seizures


4. A 30-year-old woman presents by ambulance from an outpatient surgical center with CPR in progress. She received an accidental intravenous injection of bupivacaine and suffered a convulsion, followed by cardiac arrest. In addition to standard resuscitation measures, intravenous administration of which agent should be strongly considered?
A. Fat emulsion
B. Hydroxocobalamin
C. Pyridoxine
D. Sodium nitrite


5. Which statement about the management of traumatic pulmonary contusions is correct?
A. CT findings reliably estimate the severity of pulmonary contusions
B. Management of hemoptysis is rarely a concern in pulmonary contusions
C. Respiratory support with intubation and mechanical ventilation improves outcomes
D. Restricting intravenous fluids can help prevent the need for positive-pressure ventilation

ANSWERS 

1. The correct answer is B, Retained foreign body.

Why is this the correct answer?
Vaginal foreign bodies are a rare cause of pediatric vulvovaginitis and are likely under-reported in the pediatric and adolescent literature. Obtaining an accurate history from pediatric patients can be challenging, so a subjective history is most commonly obtained from the parents. Importantly, a high level of suspicion must be maintained for possible sexual abuse in all pediatric patients presenting with vulvovaginitis. Blood-stained vaginal discharge is the most common presenting symptom, occurring in approximately 80% to 90% of all cases. Wads of tissue paper are the most common retained vaginal foreign body and comprise approximately 80% of all cases. Very young pediatric patients are generally unaware of the vagina, but later in childhood, during the process of self-exploration, they sometimes insert larger objects or toys. Placing the patient in the supine position, knees to chest, often allows for optimal physical examination of the vaginal vault. If a vaginal foreign body can be directly visualized, attempted removal using either forceps or irrigation with warmed saline is a reasonable first approach. Vaginal foreign bodies that cannot be directly visualized or are not amenable to simple removal in the emergency department require further workup, including vaginal ultrasonography, x-rays, vaginoscopy, examination under general anesthesia, or consultation with a pediatric gynecologist, depending on the resources immediately available.

Why are the other choices wrong?

  • A normal examination is certainly possible, but if parents bring a child in because of discharge, finding discharge on examination is likely. Although examining the genitals of a young child is difficult, care must be taken to look for foreign bodies, lacerations, and other trauma to localize the source of the blood.
  • Urethral prolapse presents with spotting on underwear and is identified as a red-purple mass at the opening of the urethra. Urethral prolapse is far less common, however, than retained foreign bodies.
  • Vaginal neoplasms are relatively rare in children. When they occur, they are usually rhabdomyosarcomas, but they can occasionally present as germ cell tumors or clear cell adenocarcinoma.

REFERENCES
Smock WS. Forensic emergency medicine. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosens’ Emergency Medicine Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:828-844.

Hemphill RR. Hemophilias and von Willebrand’s disease. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:1500-1504.


2. The correct answer is D, Treatment of DVT.
Why is this the correct answer?
Since 2010, the FDA has approved new anticoagulant drugs, including the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran. These anticoagulant agents have been approved for the treatment and prevention of venous thromboembolism in nonvalvular atrial fibrillation. The advantage of using one of these drugs rather than warfarin is that blood level checks, INR checks, and standardized dosing are unnecessary. This ease of use has prompted an increase in prescribing rates in an attempt to increase patient compliance and get more predictable results. The reversal of these agents is an evolving and important field of study to which emergency physicians should stay abreast. The FDA has approved idarucizumab as a reversal agent for dabigatran and andexanet alfa for the reversal of rivaroxaban and apixaban. Prothrombin complex concentrate is also frequently used to reverse the effects of these blockers.

Why are the other choices wrong?

  • The newer anticoagulant medications are not indicated to prevent blood clots in patients who have prosthetic heart valves because they have not yet proven beneficial in preventing thromboembolic complications from mechanical valves. Several studies on the new, novel oral anticoagulants are in progress, but the only published trial for dabigatran showed an increase in complications when used in patients with prosthetic heart valves.
  • Nonvalvular atrial fibrillation is a reason to use one of the new oral anticoagulant medications to prevent potential clot formation. However, the newer medications are not indicated for the prevention of atrial fibrillation itself.
  • The new oral anticoagulant agents do not act as thrombolytic agents; they only inhibit coagulation. Thus, they are not useful for treatment in an acute ischemic event such as stroke.

REFERENCES
Leung LLK, eds. Direct oral anticoagulants (DOACs) and parental direct-acting anticoagulants: dosing and adverse effects. UpToDate website. http://www.uptodate.com/contents/direct-oral-anticoagulants-dosing-and-adverse-effects. Updated January 31, 2020. Accessed January 18, 2017.

Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015 Aug 6;373(6):511-520.

Shazly A, Afifi A. RE-ALIGN: First trial of novel oral anticoagulant in patients with mechanical heart valves – the search continues. Glob Cardiol Sci Pract. 2014;2014(1):88-89.

Slattery DE, Pollack CV Jr. Thrombotics and antithrombotics. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:1524-1534.


3. The correct answer is B, Pneumonia.
Why is this the correct answer?
Pneumonia remains the most common cause of death due to complications from B. pertussis infections, especially in infants and young children. The complications from B. pertussis infections include pneumonia superinfection, CNS complications, subconjunctival hemorrhage, petechiae (particularly above the nipple line), epistaxis, hemoptysis, subcutaneous emphysema, pneumothorax, pneumomediastinum, diaphragmatic rupture, umbilical and inguinal hernias, and rectal prolapse. Many of these complications are secondary to the paroxysms of cough and increased intrathoracic and intra-abdominal pressure. Bradycardia, hypotension, and cardiac arrest can occur in neonates and young infants with pertussis. Severe pulmonary hypertension has also shown increased prevalence in this age group and can lead to systemic hypotension, worsened hypoxia, and increased mortality rates. Antibiotic treatments do not seem to reduce the severity or duration of illness. The primary goal of antibiotic therapy is to reduce infectivity and carriage. Macrolide antibiotics, including erythromycin, azithromycin, or clarithromycin, are the primary choices for therapy. Sulfamethoxazole/trimethoprim is a possible secondary choice for macrolide-allergic patients, but its efficacy is unproven. Corticosteroids can reduce the severity and course of illness, especially in young, critically ill children. Beta-agonists can be effective in patients with reactive airway disease. However, there is no evidence to support the use of pertussis immunoglobulin. Standard cough suppressants and antihistamines are also ineffective. Postexposure prophylaxis is recommended for infants younger than 6 months who have household contacts with confirmed pertussis infection because these infants have not yet completed the recommended immunization regimen.

Why are the other choices wrong?

  • Rupture of the diaphragm is certainly a complication of pertussis, secondary to coughing and increased intrathoracic and intra-abdominal pressure. However, it is not the most common cause of death.
  • Pneumothorax is also a complication of patients with pertussis, but it is not the most common cause of death either. This diagnosis should be considered if a patient’s respiratory effort suddenly increases.
  • Seizure and encephalopathy are among the CNS complications of pertussis, but neither is the most common cause of death.

REFERENCES
Fernández-Frackelton M. Bacteria. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosens’ Emergency Medicine Concepts and Clinical Practice. Vol 2. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:1693-1717.

Lefebvre CW. Acute bronchitis and upper respiratory tract infections. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:440-445.

Claudius I, Tieder JS. Sudden infant death syndrome and apparent life-threatening event. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:741-747.


4. The correct answer is A, Fat emulsion.
Why is this the correct answer?
Administration of intravenous fat emulsion (also referred to as intralipid) should be strongly considered for patients suffering severe systemic toxicity from a local anesthetic agent, such as bupivacaine. Use of fat emulsion as an antidote to local anesthetics has been studied extensively. Various animal models have demonstrated a clear benefit (although not universally so) to fat emulsion administration for systemic toxicity from local anesthetics. Multiple human case reports also suggest a benefit, although some reporting bias exists. Adverse effects have been reported, but they are infrequent and typically minor. Multiple theories on how lipid emulsion reverses toxicity have been proposed. The prevailing theory, the lipid sink theory, suggests that lipid emulsion sequesters lipid-soluble drugs away from the organ where toxicity is occurring. Administration can also be considered for patients suffering toxicity from beta-blockers, calcium channel blockers, and tricyclic antidepressants, in which standard therapies have failed. The current suggested dose is a bolus of 1.5 mL/kg of 20% lipid emulsion, followed by an infusion of 0.25 mL/kg per hour for 30 to 60 minutes.

Why are the other choices wrong?

  • Hydroxocobalamin is a precursor to vitamin B12 that is an effective antidote for cyanide poisoning. It has no known role in the treatment of local anesthetic agent poisoning.
  • Pyridoxine (vitamin B6) is used to treat acute toxicity (convulsions and altered levels of consciousness) from isoniazid poisoning. Like hydroxocobalamin, it has no known role in the treatment of local anesthetic poisoning.
  • Sodium nitrite can be used in conjunction with thiosulfate to treat cyanide poisoning. However, it has no known role in the treatment of poisoning like the one presented in this case.

REFERENCES
Schwartz DR, Kaufman B. Local anesthetics. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:921-930.

Dillon DC, Gibbs MA. Local and regional anesthesia. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016:238-249.


5. The correct answer is D, Restricting IV fluids can help prevent the need for positive-pressure ventilation.
Why is this the correct answer?
Patients with traumatic pulmonary contusions may benefit from restricting intravenous fluid resuscitation to only that which is necessary to support the intravascular volume. Over-resuscitation with intravenous fluids can increase pulmonary edema and hypoxia. When intravenous fluids are necessary, crystalloid solution is theoretically preferred; the concern with colloid solution is the sequestration of fluid in the alveoli as a sequela of increased permeability and pulmonary capillary leak. Avoiding colloid solution, however, is controversial. Both pulmonary hygiene (previously known as pulmonary toilet) and pain control to improve lung expansion and decrease splinting help to improve pulmonary function in patients with severe pulmonary contusions. In initial evaluations, early x-rays are often unable to show the severity of contusions. The most severe pulmonary contusions can actually occur without evidence of rib fracture. This finding is thought to be due to the fact that, in younger patients, the relative chest wall elasticity can cause more force from blunt trauma to be transmitted to the lungs without fracturing the ribs.

Why are the other choices wrong?

  • X-ray findings for pulmonary contusions tend to worsen over the first 72 hours. CT is better than plain x-ray at defining the initial extent of the contusion but can also fail to reveal the severity of the contusion.
  • Hemoptysis is a relatively common finding in pulmonary contusions. Auscultation of the chest may reveal rales or decreased breath sounds. Massive hemoptysis is more concerning for a pulmonary laceration.
  • Studies have shown that patients who are intubated and mechanically ventilated have higher complication rates, including increased lengths of stay and pneumonia. For alert patients, noninvasive positive-pressure ventilation is the preferred oxygenation treatment.

REFERENCES
Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosens’ Emergency Medicine Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:431-458.

Byyny RL. Blunt chest trauma. In: Wolfson AB, Cloutier RL, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer; 2015:205-212.

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