Questions, Board Review

Board Review Questions: December 2019

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 19-year-old woman presents with pain and decreased hearing in her right ear since the night before. Her ear is tender to palpation, especially at the tragus. The canal is erythematous, and the tympanic membrane, although difficult to visualize fully, appears normal. What is the best treatment for this condition?
A. Oral beta-lactam antibiotics
B. Oral corticosteroids and acyclovir
C. Surgical debridement
D. Topical corticosteroid and antibiotic solution


2. A 24-year-old black man presents with a mild headache. He describes it as dull, on both sides of his head, and in the front. When asked if he feels sensitive to light or sound, he says no. His vital signs include BP 185/100, P 88, R 14, and T 37°C (98.6°F). He has no chronic medical problems and takes no medications or recreational drugs; he does not have a primary care physician. A physical examination reveals normal mental status; the findings of ophthalmoscopic, neurologic, cardiac, and pulmonary examinations are normal. After a period of monitoring, his blood pressure is 180/105. What is the best course of action?
A. Admit the patient to a monitored acute care unit in the hospital for treatment
B. Give prochlorperazine and diphenhydramine and then discharge him when the pain resolves
C. Order a basic metabolic panel, consider starting hydrochlorothiazide, and arrange for outpatient follow-up
D. Order laboratory testing, including a CBC, basic metabolic panel, and urinalysis


3. Which therapeutic intervention has been shown to decrease mortality rates for acute respiratory distress syndrome?
A. Broad-spectrum antibiotics
B. Low-tidal-volume mechanical ventilation
C. Packed RBC transfusion
D. Prophylactic methylprednisolone


4. An accidental ingestion of which single pill by a 1-year-old (weight 10 kg) is potentially life-threatening?
A. Acetaminophen 500 mg
B. Aspirin 325 mg
C. Ferrous sulfate 325 mg
D. Glipizide 5 mg


5. A 20-year-old man presents with a gunshot wound to the right chest. He is awake and alert. His vital signs are BP 102/67, P 128, and RR 40. Bilateral breath sounds are present but diminished on the right. His neck veins are flat, and his trachea is midline. A supine chest x-ray demonstrates diffuse haziness of the right lung field, a normal mediastinum, and visible costophrenic angles. What is the appropriate next step?
A. Order a chest CT with IV contrast
B. Place a large-bore thoracostomy tube
C. Send the patient to the OR for a thoracotomy
D. Transfuse type-specific packed RBCs

ANSWERS 

1. The correct answer is D, Topical corticosteroid and antibiotic solution.
Why is this the correct answer?

The normal tympanic membrane, erythematous ear canal, and tender pinna and tragus indicate that this patient has otitis externa. Topical treatment such as a corticosteroid-antibiotic combination solution is the correct approach. Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus, usually following conditions that alter the normal external ear canal flora. Warm temperatures and exposure to moisture increase the risk for otitis externa, hence the common name “swimmer’s ear.” Direct trauma to the ear, such as use of a cotton-tipped applicator for cleaning, can also precipitate otitis externa. Again, the treatment for otitis externa is primarily topical. Although steroid-antibiotic combination drops are most commonly used, simple acidifying therapy with boric acid or acetic acid is also effective. The key is to get the drops to the canal where they are needed. If the ear canal is so swollen that it is closed, putting a cotton wick into the canal can help get the drops closer to the tympanic membrane. Malignant otitis externa, or necrotizing otitis externa, is an aggressive form of the disease occurring in immunocompromised hosts, usually patients with diabetes. It is caused by P. aeruginosa and characterized by local invasion of infection into the skull and underlying structures. Complications include meningitis and cerebral abscesses.

Why are the other choices wrong?

  • Oral beta-lactam antibiotics are the primary therapy for acute otitis media. The sine qua non of acute otitis media is a bulging, nonmobile tympanic membrane.
  • Oral corticosteroids and acyclovir are used to treat Ramsay-Hunt syndrome, which is a herpes zoster infection of the cranial nerve associated with the ear. The same therapy is recommended for Bell palsy, which is also thought to be caused by a herpes virus.
  • Surgical debridement is not recommended for most cases of otitis externa. It can be necessary, however, in cases of necrotizing otitis externa that fail to respond to prolonged antibiotic therapy.

REFERENCES
Morrissey T, Lissoway JB. Ear emergencies. In: Adams JG, Barton ED, Collings JL, DeBlieux PMC, Gisondi MA, Nadel ES, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2013:226-235.

Pfaff JA, Moore GP. Otolaryngology. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:931-940.


2. The correct answer is C, Order a basic metabolic panel, consider starting hydrochlorothiazide, and arrange for outpatient follow-up.
Why is this the correct answer?
Focused laboratory testing can be useful for certain patient populations. For patients with asymptomatic hypertension, laboratory testing for renal dysfunction can be valuable. Because this patient has no primary care physician, it may be difficult for him to obtain short-term medical follow-up care. According to a level C recommendation in the ACEP clinical policy on hypertension, for patients with “poor follow-up,” emergency physicians may order laboratory testing to search for renal dysfunction. Another level C recommendation suggests that, for this same subset of patients, emergency physicians may start long-term blood pressure control therapy; hydrochlorothiazide is a reasonable choice for this patient until he can arrange follow-up care. Thus, a referral for outpatient follow-up is appropriate.

Why are the other choices wrong?

  • A hypertensive emergency is characterized not just by a blood pressure reading but by markedly elevated blood pressure plus end-organ damage. There is no evidence that the patient in this case has end-organ damage, so inpatient management is unwarranted.
  • Prochlorperazine and diphenhydramine are standard treatments for migraine headaches. The classic features of migraine headaches are throbbing, unilateral pain, often with nausea, vomiting, photophobia, or phonophobia. The headache described by this patient does not match this list of features, so a migraine is unlikely.
  • Laboratory testing that includes a CBC, basic metabolic panel, and urinalysis is likely excessive in this scenario. Urinalysis alone is not a very useful determination of renal function. Focused laboratory testing, however, can be useful for certain patient populations. For this patient, investigation for potential renal dysfunction may be valuable and can be done as follow-up with a primary care physician or in the emergency department at the time of presentation. Again, the justification is that the patient has no primary care physician and may have difficulty obtaining short-term medical follow-up care. This approach is consistent with the recommendation on laboratory testing for renal dysfunction in patients with “poor follow-up.”

REFERENCES
Levy PD. Hypertension. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:1113-1123.

Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM; American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul;62(1):59-68.


3. The correct answer is B, Low-tidal-volume mechanical ventilation.
Why is this the correct answer?
Acute respiratory distress syndrome (ARDS) has been generally defined for decades as PaO2/FiO2 less than 300, bilateral pulmonary infiltrates on chest x-ray, and elevated pulmonary artery pressure greater than 18 mm Hg. Although ARDS has been studied extensively, one of the only therapeutic modalities that has been found to reduce mortality rates is careful support of mechanical ventilation, notably, low-tidal-volume mechanical ventilation (initial tidal volume 6 mL/kg). Over distention of the alveola caused by high tidal volume creates high shear force and injury, which worsens the symptoms of ARDS. This is measured as plateau pressures, with the goal of keeping pressures less than 30 mm H2O. Other strategies for ventilating patients with ARDS include appropriate use of positive end-expiratory pressure, high-frequency oscillatory ventilation, and prone positioning ventilation; these interventions have been shown in studies to decrease mortality rates.

Why are the other choices wrong?

  • Sepsis is the most common etiology for ARDS. Almost 50% of cases are caused by pulmonary infiltrates, and the mortality rate for these patients is almost 40%. Broad-spectrum antibiotics can be used to treat pneumonia, but not other conditions that cause the impaired oxygenation and pulmonary infiltrates seen on chest x-rays that define ARDS. Other conditions that increase patients’ risk for developing ARDS are high-risk surgeries, trauma, pancreatitis, multiple transfusions, and drug overdoses.
  • Historically, packed RBC transfusion was an integral part of early goal-directed therapy for sepsis. More recent recommendations have not included this component of the original protocol. There is no specific support for transfusion for patients with ARDS.
  • Several studies conducted on prophylactic methylprednisolone to prevent ARDS have demonstrated worse outcomes for the group as a whole, including an increase in infection rates. However, many studies have indicated that early use of steroids in patients with ARDS does improve outcomes.

REFERENCES
Modrykamien AM, Gupta P. The acute respiratory distress syndrome. Proc (Bayl Univ Med Cent). 2015 Apr;28(2):163-171.

Shapiro NI, Zimmer GD, Barkin AZ. Sepsis syndromes. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 2. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014:1864-1873.


4. The correct answer is D, Glipizide 5 mg.
Why is this the correct answer?
Glipizide is a sulfonylurea used to treat noninsulin-dependent diabetes. Like other sulfonylureas that therapeutically act by inducing the release of preformed insulin, ingestion of a single pill can cause life-threatening hypoglycemia in children. Even potential accidental ingestions in children require a long observation period — and typically admission — to determine if hypoglycemia will develop. If hypoglycemia develops, it is treated with glucose and octreotide. Octreotide antagonizes the release of insulin and decreases the frequency of hypoglycemic episodes in sulfonylurea poisoning.

Why are the other choices wrong?

  • Ingestion of a single 500-mg acetaminophen pill in a 10-kg infant (50 mg/kg dose) will not cause liver injury and is not life-threatening. Minimum doses that can potentially cause hepatotoxicity begin at approximately 200 mg/kg.
  • Ingestion of a single 325-mg aspirin pill in a 10-kg infant (32.5 mg/kg dose) will not cause significant toxicity and is not life-threatening. Generally, toxicity begins to develop at 150 mg/kg, a dose that is easily reached with ingestions of even small volumes of oil of wintergreen, a highly concentrated formulation of methyl salicylate.
  • Ingestion of a single 325-mg ferrous sulfate pill in a 10-kg infant will not cause significant toxicity and is not life-threatening. The quantity of elemental iron is used as a guide for predicting toxicity. Ferrous sulfate is 20% elemental iron, meaning that a 325-mg pill has 65 mg of elemental iron, which is a 6.5 mg/kg dose in this case. The toxic effects of iron begin to develop at approximately 10 mg/kg of ingested elemental iron, and potentially life-threatening ingestions are generally greater than 60 mg/kg.

REFERENCES
Bosse GM. Antidiabetics and hypoglycemics. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:720-731.

Fine JS. Pediatric principles. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:415-427.

Hendrickson RG. Acetaminophen. In: Hoffman RS, Howland MA, Lewin NA, Nelson LA, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:447-464.

Hernandez SH, Nelson LS. Iron. 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; 2016:1307-1310.

Hung OL. Acetaminophen. 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; 2016:1269-1275.

Levitan R, Lovecchio F. Salicylates. 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; 2016:1265-1269.

Lugassy DM. Salicylates. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:516-527.

Perrone J. Iron. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2015:616-622.


5. The correct answer is B, Place a large-bore thoracostomy tube.
Why is this the correct answer?

For this patient, clinical suspicion of a hemothorax should be high, given the penetrating traumatic injury and diminished breath sounds; absent breath sounds and dullness to percussion also fit in the clinical picture. Identification or strong suspicion of a hemothorax with a penetrating trauma should prompt placement of a large-bore thoracostomy tube (at least 32 F) in the fifth intercostal space at the anterior axillary line on the affected side. A needle thoracostomy should be performed if there is suspicion of a tension pneumothorax, but a tension pneumothorax is less likely in this patient because he does not have hypotension, jugular venous distention, tracheal deviation, or evidence of a pneumothorax on chest x-ray. Bleeding is generally due to injured lung parenchyma, but more significant bleeding can occur with injuries to larger vessels, including intercostal arteries, intermammary arteries, hilar vessels, and great vessels. Increasingly large hemothoraces can impair venous return and ventilation, resulting in vital sign abnormalities and symptoms and signs of shock. Identification of blood on chest x-ray is best achieved with upright or lateral decubitus views compared to supine, but these usually cannot be obtained during an acute trauma resuscitation. A hemothorax can be difficult to identify on supine chest x-ray, as the blood layers posteriorly and may not actually obscure the costophrenic angle or cardiac borders, appearing only as a diffuse haziness. This can be true even for large collections greater than 1 L.

Why are the other choices wrong?

  • Chest CT has the greatest specificity and sensitivity for detecting a hemothorax; however, transporting this unstable patient to the CT scanner is unwise. His chest x-ray findings provide enough evidence of a significant hemothorax, so chest tube placement should not be delayed.
  • Massive or persistent hemothoraces (>1,500 mL of initial tube output or continued output of >200 mL/hr in the first several hours) should prompt consideration of surgical thoracotomy. Chest tube thoracostomy is still the initial intervention of choice because it can lead to a clinical improvement in the patient’s condition.
  • In a trauma patient with a gunshot wound, transfusion of type-specific packed RBCs is a critical action if there is a likelihood that hemorrhage is causing the concerning vital signs. However, with the classic ABCs of trauma, an emergent airway or breathing problem should be treated first; in this case, placing a chest tube is likely to stabilize the patient’s condition. He may still need blood replacement, but if the tachycardia and tachypnea resolve, it may be unnecessary.

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

Jones D, Nelson A, Ma OJ. Pulmonary trauma. 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; 2016:1740-1752.

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