Questions, Board Review

Board Review Questions: February 2021

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 34-year-old man is transferred from a long-term care facility shortly after inadvertently pulling out his gastrostomy tube. A review of his records shows that it was surgically placed 6 days earlier without complication. He has mild abdominal tenderness and is otherwise well appearing with stable vital signs. What is the most appropriate next step?
A. Apply a sterile occlusive dressing to the opening and arrange follow-up care
B. Obtain surgical consultation while considering imaging and intravenous antibiotics
C. Replace it with a similarly sized gastrostomy tube or Foley catheter to maintain tract patency
D. Use a wire and Seldinger technique to replace it with a similarly sized gastrostomy tube


2. A 2-week-old girl presents via ambulance in shock. She was recently taken to a pediatrician to be evaluated for irritability. Which sign is most consistent with a diagnosis of congenital heart disease?
A. Bilateral pedal edema
B. Soft systolic murmur
C. Stridor and choking
D. Sweating with feeds


3. A 17-year-old girl presents with respiratory distress during an acute exacerbation of cystic fibrosis. While being treated with a nebulized beta-agonist, she suddenly arrests. She is pulseless, but some electrical activity is noted on the cardiac monitor. Her airway is controlled, and CPR is in progress. What procedure should be performed next?
A. Central line placement
B. Cricothyrotomy
C. Needle decompression of chest
D. Peripheral intravenous line placement


4. A mother brings in her 3-year-old daughter after discovering that the child had bitten into a glow-stick at a birthday party. On examination, the child is awake, alert, and in no distress, but she has a neon-yellow coating around her mouth and on her tongue. She is tolerating her secretions without difficulty. Her vital signs include BP 77/58, P 105, and R 28; SpO2 is 98% on room air. What is the best next step?
A. Administer oxygen via nasal cannula
B. Begin decontamination using activated charcoal
C. Get information about the time and amount of ingestion
D. Send blood samples for co-oximetry evaluation


5. A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating. What is the appropriate next step in management?
A. Admit the patient to the hospital for overnight observation
B. Clear the patient to return to play after 48 hours if his symptoms resolve
C. Discharge with instructions to get follow-up care and not return to play
D. Order a head CT to rule out the presence of an intracranial bleed or swelling


ANSWERS 

1. The correct answer is B, Obtain surgical consultation while considering imaging and intravenous antibiotics.

Why is this the correct answer?
Most gastrostomy tube (G-tube) tracts mature after 2 to 3 weeks, and dislodgement of the G-tube puts patients at risk for intestinal content leakage and peritonitis. Imaging, antibiotics, and surgical consultation are typically recommended. Attempting to replace a G-tube or Foley catheter into the tract before the tract matures can create a false lumen or worsen intraperitoneal leakage.

In distinction, if the G-tube had been in place long enough for the tract to mature (2 to 3 weeks), emergent replacement with another G-tube is indicated to maintain tract patency. Maintaining temporary patency with a Foley catheter (typically 16 Fr or 18 Fr) is an acceptable alternative. To confirm that the tube has been replaced correctly, about 25 mL of a water-soluble contrast material should be injected through the tube then checked with a supine abdominal x-ray.

Why are the other choices wrong?

  • Conservative wound management by applying an occlusive dressing may be appropriate after surgical consultation. However, this patient likely requires observation and potentially alternative parenteral access.
  • Inserting a replacement G-tube or temporary Foley catheter to maintain tract patency is the appropriate intervention only after the tract has matured, which takes about 2 to 3 weeks. If replacement is attempted before the tract matures, it can create a false lumen or worsen intraperitoneal leakage.
  • If the G-tube had been in place long enough for the tract to mature (2 to 3 weeks), then emergent replacement with another G-tube is indicated to maintain tract patency. Using a wire to insert a similarly sized G-tube carries the risk of creating a false lumen, but this procedure may be performed by a consultant with sufficient experience.

REFERENCES

Prosser B. Common issues in PEG tubes—what every fellow should know. Gastrointest Endosc. 2006 Dec;64(6):970-972.

Witting MD. Gastrointestinal procedures and devices. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill; 2020:551-556.

Lee AW, Hess JM. Esophagus, Stomach, and Duodenum. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 9th ed. Elsevier; 2018:1067-1082.


2. The correct answer is D, Sweating with feeds.

Why is this the correct answer?

With advances in imaging technology, congenital heart disease (CHD) can be diagnosed in utero or in the newborn nursery. However, some disorders are not diagnosed until several weeks of life when the ductus arteriosus closes, and even then, the signs are subtle and easily missed. The most common indicators of CHD are poor feeding with or without sweating, irritability, unexplained hypertension, hepatomegaly, and a pathologic murmur. On presentation, neonates with undiagnosed CHD often have mottled skin, cyanosis, and shock. Shock or cyanosis occurring in the first 2 weeks of life is very alarming, and an undiagnosed CHD should be strongly considered given that the ductus arteriosus is closing. Treatment with prostaglandins can be lifesaving. Other more common diseases such as septic shock must also be considered and treated as required in the critically ill neonate.

Why are the other choices wrong?

  • Peripheral edema as a manifestation of heart failure is rare in infants. The most common indicators of CHD are poor feeding with or without sweating, irritability, unexplained hypertension, hepatomegaly, and a pathologic murmur.
  • Murmurs are common in pediatric patients, present in more than 50% of newborns. Most of these patients have structurally normal hearts and have an "innocent" murmur, such as a grade 1-2 soft with normal split and normal peripheral pulses. Two of the most common murmurs are:
    • Peripheral pulmonary stenosis: a midsystolic high-pitched ejection murmur heard best at the left upper sternal border of the pulmonary area.
    • The Still murmur: a low-pitched systolic ejection murmur heard best at the left lower sternal border and often described as musical.
  • Stridor is audible breath sounds that typically originate from the extrathoracic airways. The presence of stridor indicates turbulent flow from a partial obstruction of the upper airways, glottis, or trachea. Congenital stridor presents at birth or within the first few weeks of life and is rarely life-threatening. The most common causes include laryngomalacia, subglottic stenosis, bronchogenic cysts, tracheomalacia, gastroesophageal reflux, and foreign body.

REFERENCES

Bakes K, Sharieff GQ. Neonatal cardiopulmonary resuscitation. In: Adams JG, Barton ED, Collings JC, DeBlieux PMC, Gisondi MA, Nadel ES, eds. Emergency Medicine Clinical Essentials. 2nd ed. Elsevier Saunders; 2013:97-102.

Kearney RD, Lo MD. Neonatal resuscitation. In: Walls RM, Hockberger RS, Gausche-Hill M, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 2. 9th ed. Elsevier; 2018:2032-2041.


3. The correct answer is C, Needle decompression of chest.

Why is this the correct answer?

This patient has pulseless electrical activity (PEA). Given her medical history of cystic fibrosis (CF) and the "H's" and "T's" of PEA, decompression of the bilateral lungs should be performed. There should be a strong suspicion that the cause of the patient's cardiac arrest is respiratory in nature because of the history of CF and the fact that she was being treated for respiratory difficulties prior to the event. Pneumothorax is a common complication of CF (the second most common cause of chest pain in these patients) and occurs much more commonly than in the general public (up to 3.5% of CF patients develop a spontaneous pneumothorax, and there is a 20% recurrence rate). Given the high rate of spontaneous disease, the patient with PEA should be assessed and if found, treated rapidly for a tension pneumothorax. If the patient is already intubated, the mnemonic, DOPE — Displacement of the endotracheal tube, Obstruction within the endotracheal tube, Pneumothorax, and Equipment malfunction — can indicate causes for acute respiratory decompensation. This is especially true in intubated patients who are being moved from one position to another.

Why are the other choices wrong?

  • Although access is an important component of CPR, central line placement would not be a lifesaving procedure for this patient.
  • A cricothyrotomy is unwarranted in this patient since there is no indication of upper airway obstruction (as would be found in a patient with acute anaphylaxis or foreign body obstruction). Patients with cystic fibrosis do have an increase in mucus production, but this causes lower airway obstruction, not upper airway obstruction.
  • This patient is in cardiopulmonary arrest. Although a tenet of care is to obtain venous access, the crucial aspect in this case is to quickly address the potential cause for the arrest. Given the patient's clinical presentation, a tension pneumothorax is the likely cause and should be addressed.

REFERENCES

Nelson K, Neuman MI, Nagler J. Pulmonary emergencies. In: Shaw KN, Bachur EG, Chamberlain J, Lavelle J, Nagler J, Shook JE, eds. Fleisher & Ludwig's Textbook of Pediatric Emergency Medicine. 7th ed. Wolters Kluwer; 2016:969-997.

Huis in’t Veld MA, Hirshon JM. Basic cardiopulmonary resuscitation. In: Tintinalli JE, Ma OJ, Yealy DM, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill; 2020:143-149.

Dunn S. Spontaneous pneumothorax and pneumomediastinum. In: Wolfson AB, Cloutier RL, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 7th ed. Wolters Kluwer; 2021:434-436.


4. The correct answer is C, Get information about the time and amount of ingestion.

Why is this the correct answer?
This patient is in no distress, is able to swallow without difficulty, and has normal vital signs for her age. The first step in determining what medical care she needs is to get more information about the ingestion, such as when it occurred, what substance was involved (if known), how much was taken, and what interventions have been performed up to this point. In this age group, the top four ingestions are cosmetics or personal care products, analgesics, household cleaning substances, and foreign bodies (eg, toys and other miscellaneous items). The top causes of death following ingestion in children are analgesics, fumes or vapors, and cough and cold preparations. The next step is to find out more about the substance and how the ingestion should be managed. The Poison Help Line (1-800-222-1222) is a good resource on toxic ingestions for both clinicians and caretakers. Toxicology specialists can also be helpful. In this specific case, the substance in the glow-stick is actually nontoxic, as are most pediatric ingestions. Although children younger than 6 years account for almost half of all human ingestions, they account for only 1.5% of the fatalities.

Why are the other choices wrong?

  • Oxygen should be administered to a child who is in respiratory distress or exhibiting signs of hypoxia (ie, clinical or abnormal pulse oximetry/blood gas readings). In those cases, oxygen should be supplied via a nonrebreathing mask to provide the highest oxygen content possible, not via nasal cannula. Because this child has a normal respiratory rate and pulse oximetry reading, this intervention is unwarranted.
  • Activated charcoal is commonly used in the treatment of toxic ingestions because it can bind the toxic agent. However, it is important to note that activated charcoal should not be used if caustics, pesticides, hydrocarbons, alcohols, iron, lithium, or solvents are ingested.
  • Co-oximetry testing is used to determine the carrying state of hemoglobin to evaluate causes of hypoxia, such as for carbon monoxide exposure or in the evaluation of methemoglobin. It has no role in the treatment of the ingestion described in this case.

REFERENCES

Bronstein AC, Spyker DA, Cantilena LR Jr, Rumack BH, Dart RC. 2011 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th annual report. Clin Toxicol (Phila). 2012 Dec;50(10):911-1164.

O'Donnell KA, Osterhoudt KC, Burns MM, Calello DP, Henretig FM. Toxicologic emergencies. In: Shaw KN, Bachur EG, Chamberlain J, Lavelle J, Nagler J, Shook JE, eds. Fleisher & Ludwig's Textbook of Pediatric Emergency Medicine. 7th ed. Wolters Kluwer; 2016:1061-1114.

Heard K. General approach to the poisoned patient. In: Wolfson AB, Cloutier RL, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 7th ed. Wolters Kluwer; 2021:1381-1386.

The Poison Help Line

The ACEP Section on Pediatric Emergency Medicine

 

  


5. The correct answer is C, discharge with instructions to get follow-up care and not return to play.

Why is this the correct answer?
Given the mechanism of injury and the presenting symptoms in this case, concussion is likely. This patient should be kept out of sports until he is evaluated by his primary care physician. If the primary care physician is uncomfortable with concussion monitoring and follow-up, then the patient should be referred to a specialist. The CDC has specific guidelines on when a specialist is warranted, as follows: if the symptoms worsen, if the symptoms have not resolved in 10 to 14 days, or if the patient has a history of multiple concussions or risk factors for prolonged recovery (eg, headache syndromes, depression, or mood or developmental disorders).

Why are the other choices wrong?

  • Although the appropriate length of time to observe a child with a concussion in the emergency department for worsening signs and symptoms has not been definitively established, the PECARN authors recommend a 4- to 6-hour observation period; the likelihood of missing a delayed clinically important traumatic brain injury during this time seems to be rare. Inpatient observation is generally unnecessary unless the family is unable to observe the patient at home and follow appropriate instructions.
  • Generally, young athletes with concussions should not return to practice or play the same day, nor should a future return to practice or play date be given during the emergency department visit. There are progressive steps that are taken to return to sports, with monitoring for symptoms and cognitive function along the way by the physician providing follow-up care. Athletes should not progress to the next steps unless they are asymptomatic at the current level.
  • Because the patient is 16 years old, either the PECARN or the ACEP head injury guideline can be used to help decide if a head CT scan is warranted. The ACEP guideline applies to patients 16 years old and older, and PECARN to patients younger than 18 years with a GCS score of 14 or 15 and an injury less than 24 hours old. Based on this patient's injury and symptoms, a head CT is not warranted by either guideline.

REFERENCES

Petering RC. Sports-related concussion. In: Wolfson AB, Cloutier RL, Hendey GW, Ling LJ, Rosen CL, Schaider JJ, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 7th ed. Wolters Kluwer; 2021:1247-1249.

ACEP resources on mild traumatic brain injury

PECARN guidelines for head CT in children

 

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