Questions, Board Review

Board Review Questions: February 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!

1. For a patient with vaginal bleeding, which risk factor could indicate endometrial cancer?
A. Anorexia
B. Anovulatory cycles
C. More than three lifetime pregnancies
D. Multiple sexual partners


2. Which treatment option is recommended to prevent recurrences of pericarditis?
A. Anti-inflammatories
B. Colchicine
C. Narcotics
D. Steroids


3. A 14-year-old boy presents with acute shortness of breath and altered mental status 2 days after he fractured his lower leg. Petechiae are noted on his chest. His vital signs are BP 95/45, P 130, R 33, and T 38.6°C (101.4°F); SpO2 is 85% on room air. Which intervention should be performed first?
A. 1 L normal saline fluid bolus
B. Heparin bolus at 80 units/kg
C. Intralipid infusion
D. RSI and endotracheal intubation


4. A 30-year-old man presents complaining of chest pain. He says he has used “a lot” of cocaine over the past 2 days. His vital signs include BP 170/120, P 120, and T 39.9°C (103.8°F). He appears very agitated. Laboratory test results include creatinine 2.6 and CPK 8500. Which treatment should be avoided?
A. Active and passive cooling
B. Intravenous haloperidol
C. Intravenous lorazepam
D. Intravenous normal saline


5. A 22-year-old man presents by ambulance after a high-speed crash. His car hit a concrete barrier, and he was ejected. On arrival, his GCS score is 5. He has bilateral periorbital ecchymosis. Which concomitant factor significantly increases the likelihood that he will die or have a poorer outcome?
A. Heart rate
B. Hypertension
C. Hypothermia
D. Hypoxia

ANSWERS 

1. The correct answer is B, Anovulatory cycles.
Why is this the correct answer?

Endometrial cancer is the most common cancer of the female pelvic organs. It is eventually diagnosed in approximately 10% of patients with postmenopausal bleeding. Prolonged exposure to high levels of estrogen and a thickened endometrium contribute to the development of this neoplasm. Therefore, obesity, nulliparity, a longer period of fertility (early menarche/late menopause), and anovulatory cycles are risk factors for endometrial cancer. When evaluating a patient with postmenopausal bleeding, the first step is to determine the exact source of the blood. It could be coming from the urethra due to a UTI, from the vagina due to atrophy or a tear, from the rectum due to lower GI bleeding, or from the uterus. Any postmenopausal woman who presents with blood from the uterus should be referred for an endometrial biopsy to rule out endometrial cancer.

Why are the other choices wrong?

  • Patients with anorexia tend to lack cycles and lack the high estrogen levels more commonly seen in obese women.
  • Multiparity is a protective factor for endometrial cancer; women who never have children (nulliparity) have more exposure to hormonal stimulation of the endometrial lining.
  • Having multiple sexual partners exposes a woman to more strains of human papillomavirus and is a risk factor for cervical cancer, not endometrial cancer. Commercial sex workers are at high risk for cervical cancer. Celibate women are more likely to get endometrial cancer.

REFERENCES
Adams JG, Barton ED, Collings J, et al, eds. Emergency Medicine. Philadelphia, PA: Saunders; 2008:1069-1078.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. St. Louis, MO: Elsevier; 2014:273-277.


2. The correct answer is B, Colchicine.
Why is this the correct answer?
In about 5% of emergency department presentations for chest pain (not related to myocardial infarction), the diagnosis is pericarditis. For the vast majority of these patients, the underlying cause cannot be identified. First-line treatment includes aspirin and other NSAIDs; ibuprofen is effective in most cases and has fewer side effects. Evidence now suggests that the addition of colchicine (1 to 2 mg for the first day and then 0.5 to 1 mg/day for 3 months) to the standard regimen is effective in hastening the resolution of acute symptoms and also preventing recurrence rates, regardless of the cause of the pericarditis. Colchicine is also effective in cases of recurrent pericarditis.

Why are the other choices wrong?

  • Anti-inflammatory agents are the first-line therapy for pericarditis. However, anti-inflammatory medications have not been shown to change the recurrence rate. Pain usually improves significantly within days of ibuprofen therapy. If symptoms persist, an alternative NSAID is indicated. Indomethacin is often used for severe cases because of its stronger anti-inflammatory effect, although it should be avoided in patients with a history of ischemic heart disease because it can decrease coronary blood flow.
  • Narcotic medications provide pain relief for patients with pericarditis but do not change the course of the disease or reduce the likelihood of recurrence.
  • The use of corticosteroids is generally reserved for recurrent pericarditis or for the treatment of pericarditis that is unresponsive to aspirin or NSAIDs plus colchicine. Initiation of steroids early in the course of first-time pericarditis might actually be an independent risk factor for recurrence.

REFERENCES
Adams JG, Barton ED, Collings J, et al, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Saunders; 2013:514-523.

Lilly LS. Treatment of acute and recurrent idiopathic pericarditis. Circulation. 2013;127:1723-1726.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. St. Louis, MO: Elsevier; 2014:1091-1105.


3. The correct answer is D, RSI and endotracheal intubation.
Why is this the correct answer?
This patient has experienced a fat embolism to the lungs as a result of his femur fracture. The action to take immediately in this case is to perform rapid-sequence intubation (RSI) with endotracheal intubation to try to correct the hypoxia and provide positive end-expiratory pressure. Bilevel positive airway pressure is contraindicated due to his altered mental status. A fat embolus causes acute, rapid hemodynamic compromise, with hypoxia from ARDS and systemic signs of disseminated intravascular coagulation (DIC). The mortality rate associated with fat embolism is between 5% and 15%. Altered mental status can manifest as agitation or confusion initially. As the disease progresses, patients can develop petechiae, jaundice, and renal failure.

Why are the other choices wrong?

  • Treatment of a fat embolus includes aggressive supportive care. A fluid bolus to improve this patient’s blood pressure is not incorrect, but it is not the most immediate action required.
  • Pulmonary embolism (PE) is high in the differential diagnosis of a patient with hypoxia and recent fracture or immobilization, but the presence of altered mental status and petechiae is more consistent with fat embolism syndrome. A CT pulmonary angiogram can exclude the diagnosis of PE; empiric heparin is inappropriate in this case.
  • Intralipid infusion is the treatment for lidocaine toxicity. It is not indicated in this case.

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. St. Louis, MO: Elsevier; 2014:511-533.

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:1777-1791.


4. The correct answer is B, Intravenous haloperidol.
Why is this the correct answer?
A patient who has overused cocaine develops abnormalities that are typical of sympathomimetic toxic syndrome: hypertension, hyperthermia, tachycardia, and tachypnea. Any of these disorders can harm the patient, but evidence suggests that hyperthermia is the most critical. Giving this patient haloperidol or some other antipsychotic medication such as droperidol or chlorpromazine would lower the seizure threshold, which can cause dysrhythmia and worsen hyperthermia. Instead, it is appropriate to provide sedative medications to help decrease the sympathetic outflow, thus resolving the tachycardia and hypertension.

Why are the other choices wrong?

  • Hyperthermia in cocaine-toxic patients must be rapidly identified and treated. Untreated, it leads to multisystem organ failure and death. Not only should active and passive cooling not be avoided, both measures are indicated. Cooling blankets alone are likely to be inadequate. Other measures, including cold intravenous fluids, ice packs, and muscle relaxation with benzodiazepines (to prevent generation of further hyperthermia), should be used.
  • Intravenous benzodiazepines are a mainstay of treatment for cocaine toxicity. They provide sedation and temperature reduction and decrease excessive neural and autonomic stimulation. Both lorazepam and diazepam can be titrated with repeated doses to achieve improvement in vital signs and symptomatic relief. Benzodiazepines also are the first-line therapy for cocaine-induced seizures, although additional antiepileptic medications may be required.
  • Intravenous fluids should not be avoided in cocaine toxicity. Patients with cocaine-induced rhabdomyolysis should be aggressively resuscitated with intravenous fluids. This treatment helps reduce further renal injury and maintain urine output.

REFERENCES
Hoffman RS, Howland MA, Lewin NA, et al, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill; 2015:1054-1063.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 2. 8th ed. St. Louis, MO: Elsevier; 2014:1999-2006.

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:1256-1260.


5. The correct answer is D, Hypoxia.
Why is this the correct answer?

Preventing hypoxia in patients with traumatic brain injury (TBI) is of the utmost importance because untreated hypoxia with associated hypercapnia correlates with significantly poorer outcomes and increased mortality rates. Hypotension is arguably the most important factor; it alone can increase mortality rates twofold to threefold through decreased cerebral perfusion. The patient in this case has a severe TBI, as evidenced by his Glasgow Coma Scale (GCS) score, and physical examination findings suggestive of basilar skull fracture. In patients with TBI, care must be taken to avoid hypoxia, hyperthermia, and hypotension because all of these factors increase morbidity and mortality rates. Hyperthermia is associated with poorer outcomes, although the mechanism remains unclear.

Why are the other choices wrong?

  • Heart rate alone does not seem to have an effect on morbidity and mortality rates in TBI. However, tachycardia secondary to significant blood loss can increase the risk of death due to low-oxygen carrying capacity. Bradycardia can be a sign of Cushing reflex, a prequel to brain herniation.
  • Hypotension, not hypertension, is associated with increased morbidity and mortality rates in TBI. Maintaining cerebral perfusion is fundamental to improving outcomes, and actions to prevent hypotension should be taken.
  • Permissive hypothermia can actually improve outcomes in TBI, and some trauma centers recommend actively inducing hypothermia in patients with TBI. In all cases, hyperthermia should be avoided.

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 8th ed. St. Louis, MO: Elsevier; 2014:339-367.

Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014:161-162.

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