Emergency Medicine Mccqe Old Exams

Front 1

What factors predict a difficult ventilation?

Back 1

BOOTS
Beard
Obese
Older
Toothless
Snoring

Front 2

1. How is the Mallampati class used in airway assessment?

2. What other measurements can you use.

Back 2

1. Class 1 - full view of uvula and posterior pharynx.
Class 2 - full uvula.
Class 3 - partial uvula.
Class 4 - no uvula or tonsils.

2. Atlanto-Axial Cervical motion - nose to ceiling >35 degrees and chin to chest.

3. Also 3-2-1 Rule.
Normal= 3 fingers at thyromental, 2 finger mouth opening, 1 finger TMJ subluxation.

Front 3

What factors predict a difficult ventillation?

Back 3

BOOTS
Beard
Obese
Older
Toothless
Snoring

Front 4

What factors contribute to a difficult intubation

Back 4

MAP
Mallampati class abnormal
Atlanto-occipital extension <35 degrees
Pathologic condition - tumour, trauma

Front 5

What factors must be present for a nasopharyngeal airway insertion?

Back 5

Patient must have a gag reflex

Front 6

What is a definitive airway? How can it be placed?

Back 6

A cuffed endotracheal tube placed in the trachea. It can be placed by mouth, nasally, cricothyroidotomy or tracheotomy.

Front 7

What advantage does a definitive airway offer?

Back 7

It has a cuff, which reduces but doesn't prevent aspiration.

Front 8

Give 5 reasons to obtain a definitive airway.

Back 8

Five P's
1. Protect airway - aspiration
2. Pharm - administer medications NAVEL (naloxone, atropine, ventolin, epinephrine, lidocaine)
3. Pulmonary toilet - to remove tracheobronchial secretions and prevent ARDS and Atelectasis
4. Positive pressure ventilation - hypoventilation, apnea, hypoxia, status asthmaticus
5. Patency - decreased LOC, facial fractures, edema

Front 9

How can increased ICP be managed via intubation?

ER Syllabus pg2

Back 9

Intubation and hyperventillation can decrease ICP temporarily by decreasing CO2

Front 10

Which drugs can be administered via endotracheal intubation?

ER Syllabus Pg 2

Back 10

NAVEL
Naloxone
Atropine
Ventolin
Epinephrine
Lidocaine

Front 11

What is the ideal way to intubate a patient requiring a cervical collar?

ER Syllabus Pg 2

Back 11

The cervical collar should be removed and an assistant should stabilize the c-spine. Less movement of spine occurs with this technique. A jaw thrust is then performed and laryngoscope inserted.

Front 12

What is the BURP technique for intubation?

ER Syllabus Pg 2

Back 12

Backward, rightward, upward pressure on larynx in order to visualize cords.

Front 13

Why should cricoid pressure be applied?

ER Syllabus Pg 2

Back 13

To prevent aspiration during intubation in patient who is suspected of having a full stomach or with increased abdominal pressure (ascites, pregnant, obese).

Front 14

How should rapid sequence indubation or induction be performed?

ER Syllabus pg 3

Back 14

9 P's of RSI
Preparation of equipment & patient
Pre-oxygenate
Pre-medicate (lidocaine, fetanyl, atropine)
Paralysis & Induction
Protect - cricoid pressure
Place tube
Proof of placement
Post-intubation care
Paralysis & Induction meds - propofol, succinylcholine

Front 15

Succinylcholine
1. Type of agent
2. How does it work?
3. Side effects

Back 15

1. Suxamethonium chloride (succinylcholine) - depolarizing muscle relaxant. Used for endotracheal intubation.

2. Depolarizing neuromuscular blocker. Very fast onset (30s) and brief duration (5 min). Imitates acetylcholine at the neuromuscular nicotinic receptors causing depolarization. Degraded by butyrylcholinesterase, a plasma cholinesterase. Deficiency of this enzyme results in Plasme Cholinesterase deficiency syndrome and prolonged paralysis.

3. Malignant hyperthermia, hyperkalemia, anaphylaxis, fasciculations

Front 16

1. What are the adverse effects of succinylcholine?

2. Why is it a choice medication for ER intubation?

Back 16

Malignant hyperthermia, hyperkalaemia and anaphylaxis, fasciculations.

Fastest onset and shortest duration of action of all muscle relaxants. ETT can be performed within 30s, wears off in minutes if intubation unsuccessful and patient returns to spontaneous respiration.

Front 17

What are the 6 most common life threatening causes of Shortness of Breath that must be ruled out in the ER?

Back 17

PE
MI
CHF exacerbation
Asthma
Tension Pneumothorax
COPD exacerbation

Front 18

What are the 2 most common causes of bradypnea?

ER Syllabus pg 5

Back 18

Opiate intoxication and CNS event.

Front 19

How does pulse oximetry work?

ER syllabus pg 6

Back 19

Measures relative proportion of oxygenated to deoxygenated hemoglobin. This is compared to oxyhemoglobin dissociation curve.

Front 20

What mmHg of blood O2 does a PaO2 of 90% equal? Why relevant?

Back 20

1. PaO2 of 90% = 60mmHg of O2.

2. Below 60mmHg, the curve drops sharply and patient will crash quickly.

Front 21

Which states impact on pulse oximetry measurement.

ER syllabus pg 6

Back 21

Anything that decreases capillary blood flow:
Shock, hypothermia, severe anemia, vasopressors.

Front 22

Name 6 investigations you would consider in a patient with SOB.


ER syllabus pg 6

Back 22

CBC
Electrolytes - acidosis
Cardiac Enzymes - MI
D-Dimer - if indicated
ECG - MI/PE
ABG - very sensitive.
CXR

Front 23

What test can be used to assess pulmonary function in the ER?


ER syllabus pg 6

Back 23

Peak expiratory flow rate. Uses a hand held meter and gives an indication of response to treatment in COPD and Asthma.

Front 24

Define respiratory failure.

ER syllabus pg 6

Back 24

pO2 < 50mmHg. Can be with or without hypercapnia (pCO2 >45mmHg).

Front 25

What information can you garner from an ABG?

ER syllabus pg 6

Back 25

Arterial Oxygenation
CO2 retention
Alveolar ventillation
Acid-Base status
Acute vs. Chronic disease

Front 26

Define Type 1 respiratory failure.


ER syllabus pg 6

Back 26

Hypoxemia (<50mmHg) without hypercapnia (no pCO2 above 45mmHg).

Front 27

Define Type 2 respiratory failure.

What are Type 2A and 2B?

ER syllabus pg 6

Back 27

Hypoxemia (<50mmHg) with hypercapnia (pCO2 >45mmHg).

2A = normal lungs but abnormal respiratory control. Overdose, CNS trauma, Muscular dystrophy, Guillain-Barre.

2B = abnormal lungs - COPD, Asthma, CF

Front 28

What are the indications for airway protection?

ER syllabus pg 6

Back 28

The 5 Ps.
Patency - Decreased LOC, edema
Protect - aspiration
Pulmonary toilet - suction secretions fluid - immersion, COPD
Pharmacology - administer NAVEL drugs
Positive Pressure Ventilation

Front 29

What are the indications for Positive pressure ventilation?

ER Syllabus pg 6

Back 29

decreased respiratory effort
respiratory failure (pO2 <50mmHg).
Trauma causing decreased ventillation.
Increased ICP.
Hypoventilation - pCO2 >60mmHg.

Front 30

What FiO2 can you achieve with nasal prongs?

ER Syllabus pg 7

Back 30

24-44%. For each L of O2 you get a 4% rise in FiO2. Can't go above 6L without drying out nasal mucosa.

1L = 24%
2L =28%
3L =32
4L =36%
5L =40%
6L=44%

Front 31

What FiO2 can you achieve with a face mask?

Can you improve this? Why?

ER Syllabus pg 7

Back 31

Up to 50-60% at 10 L/min.

It can be improved with a double flush system. Face mask connected to 2 O2 outlets on Max = 30 L/min. Can achieve nearly 100% O2. Useful for CHF pt. who is breathing spontaneously and is responding to diuretics and afterload reducers.

Front 32

What is a double flush system?

ER Syllabus pg 7

Back 32

Face mask connected to 2 O2 outlets on Max = 30 L/min. Can achieve nearly 100% O2. Useful for CHF pt. who is breathing spontaneously and is responding to diuretics and afterload reducers

Front 33

1. When are bag-mask devices indicated?

What FiO2 can they achieve?

ER Syllabus pg 7

Back 33

1. An AMBU bag is a temporizing measure until intubation can be achieved.

2. Using a mask with an AMBU bag, you can obtain FiO2 up to 100% if done well.

Front 34

What is CPAP? How can CPAP be used?

ER Syllabus pg 7

Back 34

A mask that provides pressure during expiratory phase. Most commonly used in CHF and severe COPD exacerbations. May reduce the need for intubation.

Front 35

Give 5 risk factors for Colon cancer

Back 35

Familial adenomatous polyposis
Hereditary nonpolyposis colorectal cancer
Personal or family history of sporadic cancers or adenomatous polyps
Inflammatory bowel disease
Diabetes mellitus and insulin resistance
Cholecystectomy
Alcohol
Obesity

Front 36

What are the most common presenting symptoms of colon cancer? Give 6.

Back 36

Abdominal pain — 44 percent
Change in bowel habit — 43 percent
Hematochezia or melena — 40 percent
Weakness — 20 percent
Anemia without other gastrointestinal symptoms — 11 percent
Weight loss — 6 percent

Front 37

What is the most common tumour type in colon cancer?

Back 37

The vast majority of colon and rectal cancers are endoluminal adenocarcinomas that arise from the mucosa. Colonoscopy is the single best diagnostic test in symptomatic individuals, since it can localize lesions throughout the large bowel, biopsy mass lesions, detect synchronous neoplasms, and remove polyps

Front 38

Define Syncope

ER Syllabus pg 16

Back 38

A transient, self-limited loss of consciousness with loss of postural tone, followed by spontaneous recovery.

Front 39

1. Describe your approach to syncope.

2. What tests would you order?

ER Syllabus pg 16

Back 39

1. Cardiac (50%) Arrythmia, MI, CHF - sudden, risk factors often present
2. CNS (30%) - seizure, tumour, blood, pus - often slow onset with other symptoms and prodrome.

3. Metabolic (15%) - often history of chronic disease, prodrome.

4. Psychogenic/Vasovagal - predisposing situation - micturitional, blood, stress.

2. ECG, CBC w diff, Lytes & Extended, Glucose, Cr/BUN. If cardiac suspected then CXR and Cardiac enzymes.

Front 40

What percent of syncopal episodes have an identified cause? Which causes carry worst prognosis?

ER Syllabus pg 16

Back 40

1. 50% of syncopal episodes have a cause.
2. 1/4 are cardiac - 30% 1 yr mortality.
3. 1/4 are non-cardia - 12% 1yr mortality
4. 50% are unknown - 3% mortality

Front 41

Which risk factors increase likelihood that a syncopal episode is cardiac in origin?

ER Syllabus pg 16

Back 41

Male
Older
Arrythmias
CHF
A Fib
LVH

Front 42

How does the duration of warning period in a syncopal episode help to clarify the etiology?

ER Syllabus pg 16

Back 42

The prodromal phase is short when the cause is cardiac, orthostatic and micturational. Other causes such as metabolic, CNS and psychogenic tend to have a long period of feeling uneasy before the syncopal episode.

Front 43

1. What are the 4 major causes of syncope?

2. Which are most common?

2. What physical exam and investigations should be done in ALL syncopal patents?

ER Syllabus pg 16

Back 43

1. Cardiac, CNS, Metabolic & Psychogenic/Vasovagal

2.
a. 50% of syncopal episodes have a cause.
b. 1/4 are cardiac - 30% 1 yr mortality.
c. 1/4 are non-cardia - 12% 1yr mortality
d. 50% are unknown - 3% mortality

3. P/E - Vitals, orthostatic BP, Cardiac exam, neuro exam, DRE for occult blood
Investigations - CBC, Lytes, ECG and a EKG monitor as outpatient.

Front 44

Describe the 5 high risk factors for a syncopal episode described in the San Francisco Syncope Rule.

ER Syllabus pg 17

Back 44

1. Hx of CHF
2. Low Hb
3. Abnormal ECG
4. Hx of Dyspnea
5. Systolic BP <90 at triage

Front 45

Name 3 causes of sudden death in athletes.

ER Syllabus pg 17

Back 45

1. Hypertrophic cardiomyopathy
2. Congenital coronary artery anomolies
3. Arrythmias - Prolonged QT
4. Commotio cordis - blow to chest

Front 46

Who should be considered for admission with a syncopal episode?

ER Syllabus pg 17

Back 46

1. Older males
2. Cardiac etiology or abnormal ECG
3. Positive San Francisco Syncope Rule - Anemia, CHF, Arrythmia, Dyspnea, Abnormal ECG, Systolic BP <90

Front 47

How do you stratify risk of rabies with a dog bite? How do you treat each?

Back 47

1. Vacinnated dog - Td only
2. Unknown vaccination, known dog - Rabies vaccine + Td.
3. Unknown vaccination, unknown dog = Rabies vaccine + Rabies Immune globulin + Td.

Front 48

Why don't you vaccinate all patients with a dog bite?

Back 48

1. Expensive and short shelf life.
2. Very onerous for patient - requires 5 vaccinations over a 28 day period.

Front 49

1. What are the 3 most common organisms found in dog bites?

2. Management of dog bites?

Back 49

1. Pasteurella species, staphylococci, streptococci, and anaerobic bacteria.

2.
1. Aggressive irrigation with NS
2. Debride devitalized tissue and most heal by 2nd intention
3. 3 days of: Amox-clav 875/125 bid, cefuroxime 500mg bid or TMP-SMX 1DS bid, PLUS Metro or Clinda
4. Td prn
5. Rabies - if suspect contact public health.

Front 50

How should animal bites be treated?

Back 50

Generally:
1. Aggressive irrigation with NS
2. Debride devitalized tissue
3. Face and scalp wounds are less likely to be infected due to rich blood supply and can be closed.
4. Cat and human bites should always be left to heal by secondary intention.
5. Antibiotic prophylaxis for 3 days for deep wounds, hand and foot wounds and all wounds requiring closure.
6. Antibiotic choices include: Amox-clav 875/125 bid, cefuroxime 500mg bid or TMP-SMX 1DS bid, PLUS Metro or Clinda
7. Td prn
8. Rabies - if suspect contact public health.

Front 51

What antibiotics can be prescribed for animal bites?

Back 51

1. Antibiotic choices include: Amox-clav 875/125 bid, cefuroxime 500mg bid or TMP-SMX 1DS bid,
2. PLUS Metronidazole 500mg tid or Clindamycin 450mg tid

Front 52

1. What organisms can infect a cat scratch or bite?

2. Which causes cat scratch disease?

Back 52

Pasteurella species, staphylococci, streptococci, and anaerobic bacteria. Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease.

Cat bites can also transmit Bartonella henselae, the organism responsible for cat scratch disease.

Front 53

Clonidine:
Mech of Action
Uses
Side Effects

Back 53

1. Clonidine is an α2 adrenergic agonist. It has specificity towards the presynaptic α2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone.[3]

2. Clonidine treats high blood pressure by stimulating α2 receptors in the brain, which decreases cardiac output and peripheral vascular resistance, lowering blood pressure. Also used for opioid detoxification and neuropathic pain.

3. Hypotension, Rebound headache, dry mouth, dizziness, constipation.

Front 54

Corticosteroid side effects

Back 54

Mania
Immunosuppression
Bone loss
Thinning of skin
Easy bruising
Myopathy
Cataracts
DM2
Weight gain

Front 55

Digoxin:
1. Mech of Actions - has 2
2. Uses
3. Side effects

Back 55

digoxin, a product of the foxglove plant.

1. Inotropic effect results from the inhibition of the sodium-potassium adenosine triphosphatase (NA+/K+ ATPase) pump = increased intracellular calcium (Ca++) and sodium (NA+) coupled with the loss of intracellular potassium (K+) increases the force of myocardial muscle contraction (contractility).

2. Digoxin also increases the automaticity of Purkinje fibers but slows conduction through the atrioventricular (AV) node. Cardiac dysrhythmias associated with an increase in automaticity and a decrease in conduction may result.

3. Used in Atrial fibrillation and flutter

4. Yellow-green vision, blurred vision, Arrythmias (PVC most common), AV block and bradycardia.

Front 56

Side effects of Digoxin

Back 56

Disturbances of color vision with a tendency to yellow-green coloring.

Blurred vision and diplopia

Halos and scotomas

Junctional Tachycardia or SVT

AV Node block

Front 57

Cardiac side effects of digoxin overdose (5).

Back 57

1. any dysrhythmia.
2. paroxysmal atrial tachycardia with 2:1 block,
3. accelerated junctional rhythm, 4.torsade de pointes
5. Premature ventricular contractions (PVCs) are the most common dysrhythmia.
6. Sinus bradycardia very common.
7. First- and second- andthird-degree heart block.
8. Ventricular tachycardia is an especially serious finding.
9. Cardiac arrest from asystole or ventricular fibrillation is usually fatal.

Front 58

Side effects of Fluoroquinolones.

Back 58

Cartillage damage in children - not used in children.
Tendonitis and tendon rupture in adults.
Peripheral neuropathy
Phototoxicity
Cardiotoxicity - prolonged QTc
Renal failure in high doses

Front 59

Mechanism of action of fluoroquinolones.

Back 59

They are bacteriacidal.
Inhibit bacterial DNA gyrase from unwinding, thus preventing DNA replication.

Front 60

Furosemide
1. Classification
2. Mechanism of action.
3. Uses
4. Toxicity

Back 60

1. Loop diuretic. The name of Lasix is derived from lasts six.

2. Inhibits the Na-K-2Cl symporter in the thick ascending limb of the loop of Henle. Thus prevents re-absorption of Na+ and water.

3. Used in the treatment of congestive heart failure and edema

4. Ototoxicity, hypokalemia, nephrtitis.

Front 61

Contraindications to Fluorquinolones.

Back 61

Epilepsy
CNS lesions

Front 62

Fibrates:
1. Uses

Back 62

1. Although less effective in lowering LDL, fibrates improve HDL and triglyceride levels by increasing HDL levels and decreasing triglyceride levels, and seem to improve insulin resistance when the dyslipidemia is associated with other features of the metabolic syndrome (hypertension and diabetes mellitus type 2). They are therefore used in many hyperlipidemias.

Front 63

Fibrates
1. Mechanism of action

Back 63

Agonists of the PPAR-α (Peroxisome proliferator-activated receptor alpha) receptor in muscle, liver, and other tissues. Activation of PPAR-α signaling results in:

Increased β-oxidation in the liver
Decreased hepatic triglyceride secretion
Increased lipoprotein lipase activity, and thus increased VLDL clearance
Increased HDL
Increased clearance of remnant particles

Front 64

Side effects of fibrates.

Back 64

Myositis
Reversible increases in LFT

Front 65

Halothane
1. Use
2. Mech of Action
3. 7 Side effects

Back 65

1. Inhaled general anaesthetic
2. Inhibit excitatory glutamate or 5-HT receptors and excite inhibitory GABAA receptors and TREK.
3. Malignant hyperthermia is the most serious. Bradycardia, hypotension, respiratory depression, nausea and vomiting, anaphylactic reaction.

Front 66

HCTZ - Hydrochlorothiazide
1. Uses
1. Mechanism of Action
2. Toxicity

Back 66

1. Hypertension and edema

2. Acting on the kidneys to reduce sodium (Na) reabsorption in the distal convoluted tubule. This increases the osmolarity in the lumen, causing less water to be reabsorbed by the collecting ducts. This leads to increased urinary output.

3. Hyperkalemia, hyperuricemia, hyperglycemia

Front 67

Hydralazine
1. Mechanism of action
2. Uses
3. Side Effects

Back 67

1. Interferes with the second mesenger IP3 to inhibit Ca++ release from sarcoplasmic reticulum in smooth muscle cells. This causes relaxation of smooth muscle cells and decreased peripheral resistance, lowering BP.
2. Second line agent for severe hypertension -
3. Second line due to rebound tachycardia due to baroreceptor reflex and risk of Drug induced lupus

Front 68

Hydralazine
1. Common side effects
2. Serious side effect

Back 68

1. Common side-effects include:
Compensatory tachycardia due to baroreceptor reflex - can exacerbate or cause MI.
Headache
Loss of appetite
Nausea or vomiting
Depression
Pounding heartbeat

2. Serious = Drug-Induced Lupus Erythematosus

Front 69

Isoniazid
1. Mechanism of action
2. Uses

Back 69

A prodrug must be activated by bacterial catalase. Blocks fatty acid synthase. This process inhibits the synthesis of mycolic acid required for the mycobacterial cell wall.

2. Used in combination with Rifampin (rifampicin) to treat non-resistant TB.

Front 70

Isoniazid
1. Side effects

Back 70

Rash
Hepatitis
sideroblastic anemia peripheral neuropathy
Increased phenytoin (Dilantin) or disulfiram (Antabuse) levels and intractable seizures (status epilepticus).

Peripheral neuropathy - pyridoxine (vitamin B6) depletion

Front 71

MAOI toxicity

Back 71

Hypertensive tyramine reaction
Serotonin syndrome when combined with SSRIs.

Front 72

6 clinical features of methanol ingestion

Back 72

Visual disturbances
Retinal edema and optic atrophy
Blindness
Abdominal Pain
Anion gap metabolic acidosis
Osmolal Gap
CNS depression and death

Front 73

How does methanol become toxic with ingestion?

Back 73

Metabolized to Formaldehyde in a process initiated by the enzyme alcohol dehydrogenase in the liver.

Front 74

How is methanol ingestion treated?

Back 74

Ethanol or fomepizole.

Both of these drugs act to slow down the action of alcohol dehydrogenase on methanol by means of competitive inhibition, so that it is excreted by the kidneys rather than being transformed into toxic formaldehyde.

Front 75

Define shock.

Back 75

An abnormality in the circulatory system resulting in underperfusion of the tissues. If not corrected results in cell death and organ failure.

Front 76

Which systems can be at the root of shock?

Back 76

1. Pump - Roght or Left heart pathology
2. Vessels - Neurogenic, anaphylactic or septic shock
3. Blood - Hypovolemia, anemia or toxins displacing oxygen (CO, cyanide)

Front 77

Give 6 clinical signs of shock.

Back 77

1. CNS - Agitation followed by obtundation.
2. CVS - Hypotension (30% blood loss) & Tachycardia (after 12-15% blood loss).
3. Resp - tachypnea
4. Skin - pale and cool except in vasogenic shock (warm). Increased cap refill >2 seconds.
5. Muffled heart sounds in cardiac tamponade.
6. JVP - low JVP in hypovolemia and sepsis. High JVP in Left Vent failure, Right Heart Failure

Front 78

In shock palpating the pulses can give you an estimation of blood pressure. Describe how you can estimate systolic BP from the pulses.

Back 78

Radial = >80
Femoral = >70
Carotid = >60

Front 79

What is a normal cap refill?

Back 79

<2 seconds

Front 80

1. Describe how you estimate the degree of blood loss in shock.

2. How would you replace fluids in each?

Back 80

1. Class 1 - <750cc, Pulse <100, Normal BP, cap refill, resp, urine output. Anxious. Give 3 x 750cc NS.

2. 750-1500cc = 15-30%. HR >100, BP Normal, Increased cap refill, RR 20-30, Urine 20-30, Anxious. 3:1 IV NS (2-3L).

3. 1500-2000cc (30-40%). HR>120, Decreased BP, decreased cap refill, RR 30-40, confused. IV NS 3:1 + Blood.

4. >2000cc = >40%. HR>140. No urine, lethargic. RR>35. IV NS - 6L + Blood.

Front 81

How much fluids should you replace in shock?

Back 81

3:1 rule. Warmed Crystalloids are the fluid of choice. Blood should be added in Class 3 and 4 shock.

Front 82

When should you add packed RBCs in shock?

Back 82

In class 3 or 4 shock or when patient fails to respond to 2-3L of fluid.

Front 83

Give 6 treatments for anaphylactic shock.

ER syllabus pg 120

Back 83

IV crystalloid NS 1-2L (20cc/kg for children)
Epinephrine 0.3-0.5mg IM
Salbutamol 2-4 puffs
Antihistimines (ranitidine 50mg IV & diphenhydramine 50mg IV)
Methylprednisone 1mg/kg IV
Glucagon 1mg IV for those on Beta blockers

Front 84

Name the 3 most common allergens causing anaphylactic shock.

ER syllabus pg 120

Back 84

1. Peanuts and Tree Nuts - 50%
2. Drugs
3. Bees

Front 85

Give 4 treatments for cardiogenic shock.

Back 85

1.IV crystalloid NS
2. Inotropes - Dobutamine is used in cardiogenic shock.
3. Intra-aortic balloon pump.
4. Angioplasty.

Front 86

How should tension pneumothorax be managed?

Back 86

Needle thoracostomy followed by chest tube insertion.

Front 87

Give 6 treatments for septic shock.

ER syllabus pg 118

Back 87

1. Control airway and breathing.
2. IV fluids - NS
3. O2
4. Blood culture
5. Urine culture
6. Targeted Antibiotics or if unknown source - broad spectrum such as piperacillin-tazobactam 4.5 g IV with vancomycin 1g IV if MRSA suspected.

Front 88

Give 5 possible causes of Vertigo in a 40 year old male.

What other conditions should be considered?

Back 88

90% are vestibular
1. Peripheral Vestibular
a. Vestibular neuritis / Labarynthitis
b. Benign Positional vertigo
c. Meniere's disease

Central Vertigo
a. Acoustic neuroma
b. Intracranial disease - MS, Migraine, Posterior fossa tumour.

Other causes - 10%
Syncope/Cardiac, Stroke, Psychiatric Disease

Front 89

1. You suspect a patient you’ve just seen in ER may have cancer but you’re not sure. You’re referring the patient for an out-patient consultation. You should tell the patient:
a) Nothing. You don’t have any proof.
b) Something vague and brief – the ER is no place for this kind of discussion.
c) Something general and then answer any patient questions honestly.
d) That they are going to be fine. Worrying won’t help them.
e) Any of the above – there is no right or wrong.

Back 89

c) Something general and then answer any patient questions honestly.

Front 90

1. An oxygen saturation of 90% approximately corresponds to an arterial pO2 of:
a) 90 mmHg
b) 70 mmHg
c) 60 mmHg
d) 50 mmHg
e) none of the above

Back 90

c) 60 mmHg

Front 91

1. A 72 y/o man with no previous history of headaches presents complaining of headaches worsening over the past 2-3 weeks. All of the following are suggestive of raised intracranial pressure headache secondary to tumour, EXCEPT:
a) worse when bending forward
b) asymmetric pupils
c) better in early AM
d) associated changes in memory and mood, according to family members
e) focal weakness on examination

Back 91

c) better in early AM

Front 92

1. Symptoms of lower airway obstruction include:
a) drooling
b) “hot potato” voice
c) stridor
d) wheezing
e) crackles

Back 92

d) wheezing

Front 93

ABG
1. Normal values for pH, PaO2, PaCO2, HCO3
2. Alkalosis - how do you tell if it is resp or met?
3. Acidosis - how do you tell if it is resp or met?

Back 93

1. PaO2 80-100, PaCO2 36-44, pH 7.35-7.45, HCO3 24.
2. Alkalosis - RESP = PaCO2 <35, HCO3 <24. MET = HCO3 >24, PaCO2 >40

Front 94

1. Which statement is FALSE:
a) hypertension is an important risk factor for aortic dissection
b) the birth control pill is a risk factor of pulmonary embolus
c) cocaine use is an important cause of atypical chest pain and myocardial ischemia
d) a parent who first suffered angina at the age of 70 is an important risk factor for a 45 y/o patient with chest pain
e) chest wall tenderness is a meaningful finding only if the chest discomfort is easily and fully reproduced

Back 94

d) a parent who first suffered angina at the age of 70 is an important risk factor for a 45 y/o patient with chest pain *

Front 95

1. A bHCG test is indicated in all women of child bearing age who present with abdominal pain EXCEPT when they:
a) are not sexually active
b) have had a normal menstrual period within the last 2 weeks
c) are taking birth control pills regularly
d) have had a tubal ligation
e) have had a hysterectomy
f) all of the above

Back 95

e) have had a hysterectomy

Front 96

1. In most patients with acute asthma, the best way to assess severity of airflow obstruction is:
a) measurement of vital signs
b) assessment of wheeze and measurement of pulsus paradoxus
c) measurement of PEFR or FEV1
d) response to initial therapy with beta-agonist
e) none of the above

Back 96

c) measurement of PEFR (Peak Expiratory Flow Rate) or FEV1 and best measurement of oxygenation is an ABG.

Front 97

1. In patients with acute severe pulmonary edema not responding to first-line medications, what alternative therapy is NOT indicated?
a) Bi-PAP
b) intubation and ventilation
c) IV nitroglycerin
d) blood transfusion

Back 97

d) blood transfusion *

Front 98

10 first-line treatments of pulmonary edema secondary to CHF exacerbation

Back 98

ABCs & LMNOP
Sit upright
100% O2 non-rebreather +/- CPAP
IV D5W TKVO (to keep vein open)
Furosemide 40-80mg if SBP > 100
Nitroglycerine 0.4mg sublingual q5min - decreases preload
Morphine - reduces preload
Dopamine used in refractory disease.
Rule out MI
Should consider stat revascularization if MI present.

Front 99

What are the x-ray signs of CHF?

Back 99

Cardiomegaly
Increased vascular redistribution to upper lung fields
Interstitial edema
Kerley B line
Pleural effusions

Front 100

What is the role of Brain Natriurectic peptide in CHF?

Back 100

Elevated in CHF. Useful for diagnosis and prognosis when the clinical and other investigations are not definitive for CHF.

Front 101

What is Cushing's Response?

How should it be managed?

Back 101

1. hypertension, bradycardia, and respiratory depression. Occurs when brainstem, perfusion is compromised by increased ICP.

2. No Antihypertensives! Hyperventillate, Mannitol and STAT neurosurg.

Front 102

X. Identify his rhythm. (1 mark)

Y. What would your initial therapeutic step be? (1 mark)

Z. If this were unsuccessful, what would your next therapeutic step be? (1 mark)

4. And then?

Back 102

X. * PSVT - Paroxysmal supraventricular tachycardia
Y. * Carotid massage, Valsalva maneuver
Z. * Adenosine 6 mg IV -> 12 mg IV -> 12 mg IV injected most proximal to the heart

4. Synchronized cardioversion if no response.

Front 103

60 year old woman on coumadin for a known irregular heart beat. Asymptomatic, P 70. BP 120/75. Has not taken her metoprolol for 2 days. Came to ED because of sprained ankle.

1. Dx
2. Tx

Back 103

1. Stable Chronic atrial fibrillation..

2. Treat her ankle injury. Ask her to take her metoprolol. Follow up with GP as needed.

Front 104

75 year old male presenting with 15 second syncopal episode. Chest pain, diaphoretic, lightheaded, nauseated, BP 100/60mmHg, chest clear, known coronary artery disease.

1. Dx?

2. What medications should be avoided?

3. Tx?

Back 104

1. Mobitz Type 2.

2. Stop all drugs that slow AV conduction - Digitalis, CCB (diltiazem, amiodarone) and Beta-blockers.

3. Borderline BP and chest pain require MI Workup - may be an inferior MI.
a. Stop all meds that slow AV conduction.
b. Setup for pacing in case he develops 3rd degree block.
c. If 3rd degree block and refractory to pacing, consider Epinephrine drip.
d. Urgent referral to Cardiology for pacemaker = definitive Tx.

Front 105

Patient is pulseless and apneic.
1. Dx?
2. Action?

Back 105

1. V Fib
2. Call Code. Start CPR. Secure airway and bag mask. Start IV. Defibrilliate with 360J monophasic (200J biphasic). Defibrillation at 360 joules monophasic
(120 or 200 joules biphasic)
Epinephrine 1 mg IV q 3-5 minutes. Amiodarone 300 mg initial dose, 150 mg in 5 minutes.

Front 106

1. Are the P’s related to the QRS, (i.e. are they conducted)?
2. Dx?

Back 106

In the first strip there are P waves seen before
each complex. They conducted=sinus
arrhythmia.
2. PAC’s with artifact. (premature atrial complex)

Front 107

A 41 y/o male alcoholic is brought into the ED by ambulance. He has been seizing for approximately 20 minutes. Appropriate actions in the next 5 minutes may include all of the following EXCEPT:
a) endotracheal intubation, if unable to stop the seizure rapidly
b) administration of IV anticonvulsants
c) performing a complete set of vital signs
d) ordering a stat EEG

Back 107

d) ordering a stat EEG *

Front 108

What is this rhythm?

Back 108

Agonal rhythm
• widening of the QRS, loss of
amplitude, combined with periods of
asystole
• represents the diminished electrical
activity of a dying heart

Front 109

1. What is the rhythm?
2. How should it be managed?

Back 109

1. Wide complex tachycardia, regular, no P’s seen.
Differential Diagnosis = Ventricular tachycardia (VT) vs. Supraventricular tachycardia with
aberrant conduction. Treat as VT until otherwise proven.
2. CPR for 2 minutes. 1 shock 360J mono or 200J Biphasic. Resume CPR 5 cycles. Check Rhythm. Shockable? CPR then Shock. IV epinephrine 1mg, CPR, defib, CPR, check rhythm - fail? Amiodarone 150mg and start again.

Front 110

1. Describe what you see here.
2. What is the rhythm?

Back 110

Narrow complex, fast (up to 300 bpm in certain parts of strip), irregularly, irregular, unable to see P waves. Most consistent with rapid atrial fibrillation. At rapid rates can be difficult to discern from PSVT, look for
irregularly, irregular pattern.
In most rapids atrial fibrillation a normal AV node provides a greater level of block ie. Ventricular rate seldom goes much above 160. If ventricular rate > 200, think atrial fibrillation with bypass tract - i.e. WPW.

Front 111

15 year old boy comes to ED complaining of palpitations for 1 hour. He has had
this intermittently for years but never investigated. He recently immigrated from
a developing country. BP 110/60, P 180, chest clear.

1. What is the rhythm?

2. How is it managed?

2. A repeat ECG revealed a short PR and
a delta wave. What abnormality does he have with his heart?

Back 111

1. Wide complex tachycardia. VT until proven otherwise. Stable. Urgent - even though a patient is stable, an arrhythmia that is potentially unstable should be assessed within minutes.

2. This boy was converted to normal sinus rhythm with amiodarone. A repeat ECG revealed a short PR and
a delta wave.

3. Wolff-Parkinson-White (WPW) syndrome

Front 112

HOCM or HCM
1. Definition
2. Etiology and Age of presentation
3. Clinical Manifestations
4. PE findings
5. Dx.
6. Complications
7. Tx

Back 112

1. Hypertrophic (obstructive) cardiomyopathy. Hypertrophy can occur in any region of the left ventricle but frequently involves the interventricular septum, which results in an obstruction of flow through the left ventricular (LV) outflow tract.
2. Autosomal dominant - most common cause of sudden death in children and adolescents. Most present in their 20's and 30's. Abnormal LV outflow tract and mitral valve position results in significant ventricular pressures, futrther stimulating hypertrophy.
3. Dyspnea, syncope, pre-syncope, angina, palpatations, orthopnea, dizziness, PND.
4. Massive, displaced apex beat. S3 gallop signifies decompensated congestive heart failure. S4 from atrial systole against a highly noncompliant left ventricle. Prominent JVP, Double carotid arterial pulse.
5. ECG, CXR, 2D Echo
6. Sudden death (most common cause in children and teens), arrythmias and heart failure.
7. Beta-adrenergic blocking agents (metoprolol) - Reduce inotropic state of left ventricle. Decrease diastolic dysfunction and increase LV compliance, thereby reducing pressure gradient across LV outflow tract. Decrease myocardial oxygen consumption. Amiodarone (Cordarone) Only agent proven to reduce the incidence and risk of cardiac sudden death, with or without obstruction to LV outflow. Very efficacious in converting atrial fibrillation and flutter to sinus rhythm and in suppressing the recurrence of these arrhythmias. Surgical ablation, pacemaker, myomectomy.

Front 113

Which of the following statements about insect stings is NOT true?

a) reactions can be fatal
b) the venom of each family of stinging insect is unique
c) desensitization is of no value in prophylaxis
d) visible stingers should be removed
e) severe reactions are treated similarly to anaphylaxis

Back 113

c) FALSE. Immunotherapy can reduce recurrence in insect stings by 97%!

Front 114

1. What is the ER mgt. of Anaphylaxis?

2. How can you mitigate a delayed reaction?

3. What special circumstances may occur with a pt. on B-blockers?

4. When and how should d/c occur?

5. What is the role of immunotherapy in anaphylaxis?

Back 114

1. IV Fluids 1-2L NS IV (20cc/kg for children), O2 100% non-rebreather, Inhaled salbutamol, epinephrine 0.3-0.5mg IM q3-5min, Ranitidine 1mg/kg IV, Diphenhydramine 1mg/kg IV,

2. Methylprednisone 1mg/kg IV reduces the delayed reaction in 4-6h. All patients should receive this.

3. Glucagon 1mg IV should be given to patients on B-blockers who are refractory to epinephrine (blunts effect).

4. Watch all pts. for 6h for delayed secondary reactino. D/C on Benadryl 10mg po od, Ranitidine 150mg po od and prednisone 50mg po od all x 3d. All patients should be prescribed an epipen and instructed on use.

5. Follow up with Allergist is mandatory, and immunotherapy can be highly effective (97% reduction in insect stings).

Front 115

Medical testing after sexual assault frequently includes all EXCEPT:
a) testing for gonorrhoea and chlamydia
b) hCG testing
c) HIV testing
d) testing for hepatitis B serology

Back 115

d) testing for hepatitis B serology

Front 116

The INCORRECT statement below with regard to rabies:
a) local wound care has no effect on diminishing the risk rabies transmission
b) prompt postexposure immunoprophylaxis (on speculation) is indicated in head or infected bites, patients on corticosteroids or with immunosuppressive conditions, and in high risk regions for dog or cat rabies
c) if rabies is a big concern, wounds should not be sutured as this can promote viral replication
d) HDCV adverse reactions are usually minor reactions, and corticosteroids should be avoided if at all possible in treating reactions
e) rabies immune globulin and human diploid cell rabies vaccine can be used in pregnancy when indicated

Back 116

a) local wound care has no effect on diminishing the risk rabies transmission *

Front 117

How should a wound from an animal suspected of having rabies be managed?

What is HDCV?

Back 117

a) local wound care diminishes the risk rabies transmission - +++ irrigation
b) prompt postexposure immunoprophylaxis (on speculation) is indicated in head or infected bites, patients on corticosteroids or with immunosuppressive conditions, and in high risk regions for dog or cat rabies
c) if rabies is a big concern, wounds should not be sutured as this can promote viral replication
d) HDCV (Human diploid cell vaccine) adverse reactions are usually minor reactions, and corticosteroids should be avoided if at all possible in treating reactions
e) rabies immune globulin and human diploid cell rabies vaccine can be used in pregnancy when indicated

Front 118

A 6 mo. old boy is brought to the hospital because of a 3-day history of profuse vomiting and diarrhea. He weighs 5 kg. He has been unable to tolerate any fluid. Mother is unsure of the last urine output because of the diarrhea. On initial exam, he is lethargic, mottled and has a capillary refill of 3-4 seconds. Vital signs are BP 90/p, HR 180, RR 40. Initial fluid resuscitation of this infant should be:
a) 50cc D5W
b) 100cc D5W + 0.9% NaCl
c) 100 cc 2/3 D5W + 1/3 0.9% NaCl
d) 50cc 0.9% NaCl
e) 100cc 0.9% NaCl

Back 118

e) 100cc 0.9% NaCl = 20cc/kg

This child is showing signs of shock - mottled skin, cool extremities, diminished pulses, delayed cap refill, MS changes, oliguria and tachycardia.

Front 119

Shock in children
1. Signs of shock
2. When to begin CPR in children.
3. Calculate fluid requirements in children and methods of access.

Back 119

1. signs of shock - mottled skin, cool extremities, diminished pulses, delayed cap refill, MS changes, oliguria and tachycardia.

2. ABCs - CPR if no pulse or HR <60

3. Vascular access by IV or Intraosseous, IV NS 20cc/kg

Front 120

Cardiac arrest in children
1. Most common causes.
2. Approach to CPR
3. Fluid requirements
4. Drugs in cardiac arrest
5. When to use Defibrillation

Back 120

1. Airway and fluids are critical - Resp failure and hypovolemia are most common cause in children.
2. CPR should be started at >100BPM if pulse <60.
3. IV access via IV or interosseous with 20cc/kg bolus NS. 20cc/kg bolus, monitor response. May require up to 60cc/kg.
4. Epinephrine 1st line. Sodium bicarb with acidosis. Glucose if hypoglycemic. Atropine for bradycardia. Dopamine is 2nd line.
4. Defibrillation is rarely indicated in children as pulseless VF/VT is uncommon. Most cardiac arrests are asystolic or bradycardic and thus difibrillation is contraindicated. Defib is indicated for VF or pulseless VT (1J/kg). Synchronized cardioversion for SVT and VT with poor perfusion and hypotension.

Front 121

75 year old male in ER for syncope. He vomits as the nurse is starting an IV and
becomes confused and less responsive. BP 60 mmHg.
1. Dx.
2. What drugs should be avoided or d/c?
3. Give 5 Tx

Back 121

1. Third degree Heart block
2. Stop all drugs that slow AV conduction - Digitalis, CCB (diltiazem, amiodarone) and Beta-blockers.
3.
a. Stop all drugs that slow conduction.
b. Evaluate for MI - particularly Inferior - thus 15 lead ECG
c. Transcutaneous pacing
d. If refractory consider epinephrine drip
e. Urgent consult cardiology for pacemaker -> definitive Tx

Front 122

A 24 mo. old child is brought to the ED with a temperature of 39C rectally. Parents state she has had the fever for 5 days now and feel she is less active than normal. On exam the child is quiet and cooperative and no focus of infection is found. You decide to do the following investigations:
a) chest X-ray
b) mono spot
c) CBC with differential, blood culture and urinalysis
d) none as the child does not appear lethargic or toxic
e) NP swab and viral cultures

Back 122

d) none as the child does not appear lethargic or toxic
Rule:
Temp < 39.5, nonlethargic, nontoxic and no focus = observation and follow up in 24 hours. See ER syllabus 153.

Front 123

Rochester Criteria
1. Who is it used for?
2. What is the goal?
3. What factors are considered?

Back 123

1. Infants <60 days who appear well (non-toxic) with a fever.
2. If criteria are fulfilled febrile infant is <1% chance of having a serious bacterial infection.
3.
a. PMH - Term, no Hx of Abx, no Hospitalizations or delayed discharge after birth, no chronic illness, no Hx of unexplained Hyperbilirubinemia
b. PE - no evidence of skin, soft tissue, bone, joint or ear infection.
c. Labs - WBC 5-15, Bands <1.5, Urine WBC <10, Stool WBC <5 if diarrhea.

Front 124

How should the following febrile children be approached:
a. 20 days old
b. 2 months old
c. 5 months old

2. Define a full sepsis workup

3. What antibiotics should each group get?

Back 124

a. <30d - all febrile infants under 30 days get full septic w/u + Amp + cefotaxime or Amp + gent.

b. 30d-3mo
-Lethargic/Toxic - full sepsis w/u, Amp + cefotaxime or Amp + gent.
-Nonlethargic/nontoxic - CBC w diff, urinalysis, blood and urine cultures -
-High risk Rochester = Abx,
-Low risk Rochester = d/c or admit, no abx + observe.

c.2 months
-Lethargic/Toxic = full sepsis w/u + cefuroxime/ceftriaxone.
-Nonlethargic/toxic = Temp <39.5 f/u 24h. Temp >39.5 consider CBC w diff, urinalysis, Urine + blood culture.
-Low risk - no Abx, 24h f/u.
-High risk Rochester - Amox + f/u 24h pending results.

2. Full sepsis w/u - CBC w diff, Urinalysis, Blood/Urine/CSF culture +/- CXR if resp Sx.

3.
a. <30 Amp + cefotaxime or Amp + gent.
b. 30d-3mo Amp + cefotaxime or Amp + gent.
c. 3-36 months - cefuroxime or ceftriaxone.

Front 125

1. What % of otitis media infections are viral?

2. What are the common bacterial pathogens?

Back 125

1. Up to 80% of otitis media infections are viral - hence no role for Abx.

2. Common bacteria are - H. inf (non-typeable), streptococci, staph, e. coli

Front 126

How should Otitis Media be managed in:
1. <6m
2. 6m - 2 y
3. >2y

Back 126

(i) <6 mths - Antibacterial therapy x 10d
(ii) 6 mths to 2 yrs- Antibacterial therapy x 10d (if certain dx or severe illness); watchful waiting & re-assess in 48-72 hrs if
uncertain & non-severe illness (tx symptoms)
(iii) > 2 yrs - Antibacterial therapy x 10d if certain, severe illness; watchful waiting & re-assess in 48-72 hrs if non-severe or uncertain illness, and tx symptoms (this is recommended in most over 2 years).

1st Line Antibiotics:
Amoxicillin 80mg/kg/day divided BID or TID

Front 127

Streptococcal Pharyngitis
1. McIsaac Criteria
2. Treatment

Back 127

Streptococcal Pharyngitis
McIsaac Criteria:
Symptoms: temperature > 38°C, no cough, swollen and tender
anterior cervival nodes, tonsillar swelling or exudates, age 3-14 yr

Treatment: score ≤1 (no culture, no antibiotic), score 2 or 3
(culture, treat if positive), score 4 or 5 (antibiotics)
o Penicillin V 25-50mg/kg/day PO bid x10days
o Erythromycin 40mg/kg/day PO tid x10 days (if penicillin
allergic)
Note: 80-90% of pharyngitis is viral  no abx indicated; r/o epiglottitis, peritonsillar or retropharyngeal abscess

Front 128

Uncomplicated UTI
1. Give 4 Abx choices

Back 128

Uncomplicated UTI
1st line:
Cephalexin (Keflex) 25-50mg/kg/day PO divided q6h x 7-10d
OR
TMP/SMX 5-10mg/kg/day PO, trimethoprim divided q12h x 7-10d
2nd line:
Amoxicillin 40mg/kg/day PO divided q8h x 7-10d
Nitrofurantoin

Front 129

Describe the Tx of an asthma exacerbation in the ER. Give 8 steps.

Back 129

1. O2 if sat <90%
2. Salbutamol by MDI 2-4 puffs q20 min.
.3 Multiple doses of salbutamol will require K+
4. Ipratropium bromide250mcg for first 3-6 doses in severe disease.
5. Prednisone 2mg/kg in ER + 1mg/kg x 4d.
6. Magnesium sulfate 20-40mg/kg IV over 20 min for severe disease.
7. IV salbutamol for non-responders
8. Intubate if refractory at this stage.

Front 130

Asthma exacerbation discharge
1. give 4 orders

Back 130

1. Ventolin/Salbutamol by MDI with spacer - 4 puffs q4h x 24h, then 2 puffs qid x 1wk.
2. Pediapred/Prednisone 1mg/kg x 5d
3. Flovent 100mcg qam x 1 wk after oral steroids
4. Mandatory f/u w/in 48 hrs after d/c from ER

Front 131

Bronchiolitis
1. Define
2. Etiology
3. Seasonal spike
4. Sx
5. Tx
6. Admission criteria

Back 131

1. First episode of wheezing with cough in a child under 2.
2. Viral, usually RSV
3. Peaks December-April
4. Cough, fatigue, difficulty eating/nursing, crepitations.
5. O2 by hood is best if <90%, IV fluids 10-20cc/kg, trial of salbutamol - d/c if non-responsive. Observe & f/u 24h. No Abx!
6. Admit if <2mo, dehydrated, O2<90%, respiratory distress, Hx of respiratory/cardiac disease.

Front 132

Croup - Laryngotracheobronchitis
1. Define
2. Etiology
3. Sx (5)
4. Tx (3)

Back 132

1. viral infection of the upper trachea and larynx
2. Parainfluenza virus
3. Fever, preceded by URTI, barking cough, hoarse voice, inspiratory stridor, respiratory distress, onset at night.
4. Dexamethasone 1mg/kg 1 dose. Epinephrine 1:1000 2.5ml for severe Sx. Admit if no response in 4h.

Front 133

An 8 y/o girl with a history of a viral-like illness 2 weeks ago and a 1 week history of difficulty passing hard, infrequent stools. Her appetite is not as good as usual according her father. Investigations for this condition include:
a) abdominal X-ray
b) urinalysis
c) stool culture
d) CBC with differential and electrolytes
e) abdominal ultrasound

Back 133

b) urinalysis - she is dehydrated

Front 134

A 10 y/o boy presents to the ED after twisting his ankle while playing soccer. He is unable to weight bear and is complaining of pain over the lateral of his ankle. On examination he has tenderness and swelling over the lateral malleolus. X-ray of his ankle does shows no evidence of fracture. Optimal treatment for this child includes:
a) rest, ice, elevation of his foot, return if not improved in 1 week
b) rest, ice, crutches, ambulate as tolerated
c) immobilize the leg in a cast, crutches
d) rest, ice, tensor bandage and crutches

Back 134

c) immobilize the leg in a cast, crutches - see Ottawa ankle rules

Front 135

Ottawa Ankle Rules
1. Who gets an ankle X-Ray?
2. Who gets a foot x-ray?
2. Who gets a cast?

Back 135

Ottawa rules only apply to patients older than 16 and under 65.

1. Bony tenderness at Posterior Medial OR Lateral Malleolus OR inability to weight bear BOTH immediately and in ER

2. Pain in ZONE 2 - (Navicular to 5th metatarsal) AND bony pain on Navicular or 5th metatarsal OR inability to weight bear immediately and in ER.

3. Cast those who fulfill the Ottawa ankle rule and don't have a fracture, with ortho f/u.

Front 136

10. A patient intoxicated with OTC diet pills complains of palpitations and chest pain. Physical examination reveals that the patient is tachycardic at 150 with a blood pressure of 180/110. Which on of the following substances would present with the same toxidrome?
a) theophylline
b) diphenhydramine
c) nortryptiline
d) phenytoin
e) carbamazepine

2. What syndrome would the other substances present with?

Back 136

ANSWER = Theophylline is a sympathomimetic. Hypertension, tachycardia, mydriasis, diaphoresis, sweats, seizures.

a) theophylline
b) diphenhydramine - anticholinergic
c) nortryptiline - anticholinergic
d) phenytoin - anticholnergic
e) carbamazepine - anticholinergic

2. The others will present as an anticholinergic syndrome. Red, hot, dry, blind.

Front 137

1. Describe a sympathomimetic toxidrome.

2. Name 4 drugs that cause this toxidrome.

3. Give 4 broad approaches to treatment of this toxidrome.

Back 137

1. sympathomimetic. Hypertension, tachycardia, mydriasis, diaphoresis (sweating), seizures.

2. Amphetamines, ASA, Cocaine, LSD, PCP, Theophyllines, alcohol and benzo withdrawal.

1. ABCs - IV Fluids, Oxygen, Intubate if necessary, monitors
2. Give universal antidotes - Oxygen, Thiamine, Glucose, Naloxone.
3. Specific treatments once toxidrome identified - Benzos, mist/cooling fan.

Front 138

Cholinergic Toxidrome
1. 7 manifestations
2. 3 drugs causing it
3. Treatment

Back 138

1. Due to inactivation of acetylcholinesterase - salivation, lacrimation, incontinence, diarrhea, bronchospasm, bronchorrea, bradycardia, vomiting

2. Carbamates (insecticide), organophosphates (insecticide) and nerve gas.

3. Decontaminate with charcoal if within an hour, atropine, 2-pam, hemodyalisis

Front 139

An 18 y/o female is brought from a house party, agitated and combative. Which feature of her physical examination would reveal whether her presentation was secondary to diphenhydramine versus “Ecstasy” (a designer amphetamine)?
a) heart rate
b) respiratory rate
c) temperature
d) pupil size
e) presence/absence of diaphoresis

2. How would you treat:
a. Ecstacy
b. Diphenhydramine
c. Organophosphates
d. Morphine

Back 139

e) presence/absence of diaphoresis *
Ecstasy is a sympathomimetic and will cause diaphoresis, tachycardia, hypertension, agitation Mydriasis (dilated pupils). Diphenhydramine is an anticholinergic and will cause red, hot and dry with tachycardia, mydriasis, urinary retention, hyperthermia but not hypertension or diaphoresis.

2.
a. IV fluids, benzos, mist/cooling fan
b. IV fluids, benzos, mist/cooling fan
c. IV Fluids, Atropine and 2-PAM
d. IV Fluids, Naloxone

Front 140

What is diaphoresis?

Back 140

excessive sweating.

Front 141

A 48 y/o man who is known to drink large amounts of alcohol on a daily basis presents to the ED with severe abdominal pain of 3 hours duration. A reasonable differential diagnosis for the cause of this man’s pain includes all of the following, EXCEPT:

a) bleeding esophageal varices

b) alcoholic ketoacidosis

c) perforated duodenal ulcer

d) acute pancreatitis

e) spontaneous bacterial peritonitis

Back 141

a) bleeding esophageal varices are generally painless and will present with weakness, shock, vomiting, anemia.

Front 142

A 40 y/o man presents after a stab wound to the left chest, complaining vigorously of shortness of breath. On examination, he is pale, diaphoretic, and has a blood pressure of 60/40. Your clinical evaluation determines the presence of a left sided tension pneumothorax. Your initial management in this patient involves which one of the following:

a) 2 large bore IV’s and 2000 cc Ringer’s Lactate bolus

b) nasotracheal intubation

c) insertion of a needle in the left second interspace, midclavicular line

d) left tube thoracostomy, fifth interspace, midaxillary line

Back 142

c) insertion of a needle in the left second interspace, midclavicular line followed by insertion of a chest tube.

Front 143

The most important historical feature to ascertain in the assessment of head trauma is:

a) seizure activity

b) windshield damage

c) loss of consciousness

d) nausea & vomiting

Back 143

c) loss of consciousness *

Front 144

Canadian CT Head Rule
1. Define High risk criteria
2. Define Medium risk criteria
3. Define Low risk criteria

Back 144

CT Head Rule is only required for patients with minor head injuries with any one of the following:
High risk (for neurological intervention)
● GCS score <15 at 2 h after injury
● Suspected open or depressed skull fracture
● Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)
● Vomiting - two or more episodes
● Age >65 years
Medium risk (for brain injury on CT)
● Amnesia before impact >30 min
● Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)
Minor head injury is defined as witnessed loss of consciousness, definite
amnesia, or witnessed disorientation in a patients with a GCS score of 13–15.

Front 145

Jones Fracture
1. Etiology
2. Description
3. Management

Back 145

1. Ankle roll-over is most common cause.
2. Transverse fracture of the base of the 5th metatarsal.
3. Weight bearing worsens the fracture. Predisposed to non-union. Thus must immobilize in a posterior slab and arrange ortho follow-up.

Front 146

1. What kind of fracture is this?
2. How does it happen?
3. How would you manage it?

Back 146

1. An avulsion fracture of the base of the 5th metatarsal (pseudo-jones)
2. Occurs with inversion ankle rollover when due to traction from the peroneus brevis.
3. Heals well with below the knee immobilization cast x 3wks and ortho followup.

Front 147

What is the most common reason that a fracture would threaten life immediately?

Name 3 delayed threats to life with a fracture.

Back 147

1. Blood loss

2. Sepsis, Fat embolism and DVT/PE.

Front 148

How much blood can be lost with the following fractures:
1. Pelvis
2. Femur
3. Tib/Fib

Back 148

1. 3 L
2. 1.5 L
3. 750cc

Front 149

What are the 5 P's of compartment syndrome?

Back 149

Pain
Pallor
Paresthesia
Pulseless
Paralysis
Polar (cold)

Front 150

1. What injury is this?

2. How does it occur

3. What is the most common complication that must be avoided?

4. How is it treated?

Back 150

1. Anterior shoulder dislocation. >95% of dislocations are anterior
2. Occurs with abduction and external rotation.
3. Must reduce to avoid damage to the axillary nerve which supplies deltoid and sensation to lateral shoulder.
4. Sedate with fentanyl and medazolam. Reduce with traction-counter-traction or Stimson Method (prone on bed with weight on wrist). X-ray to confirm reduction. Immobilize in sling and ortho followup.

Front 151

1. Name 2 methods to reduce a shoulder dislocation.

2. What other treatments should be done?

Back 151

1. Traction-counter-traction method & Stimson method.

2. Confirm that axillary nerve is patent. Then must sedate, then reduce, then immobilize, then confirm reduction with x-ray.

Front 152

Lateral Elbow X-Ray
1. Describe a. and b.
2. What does a. signify?
3. What does b. signify?

Back 152

1. These are signs of an elbow effusion - a pronounced anterior is abnormal. ANy fluid collected in the posterior fat pad is abnormal.
2. Anterior effusion - may signify an occult radial head fracture or a supracondylar fracture.
3. Posterior fat pad sign - occult radial head fracture or a supracondylar fracture.

Front 153

Calcaneal Fracture
1. What mechanism usually causes this injury?
2. What must you rule out with this injury?
3. How should it be managed?

Back 153

1. Jumping from a height or vehicle crash.
2. Must assume and rule out ankle, knee, hip, pelvis, lumbar fractures.
3. Immobilize and urgent ortho consult.

Front 154

Some wounds require oral antibiotics routinely. Which of the following wounds necessitate the use of antibiotics?
a) road rash
b) dog bites
c) cat bites
d) puncture wounds to the foot

2. Give 2 antibiotic choices

Back 154

c) cat bites are almost always puncture wounds and are considered high risk.

2. 1st line = Amox-clav. 2nd Gen ceph (cefuroxime). 3rd line - clindamycin plus cipro.

Front 155

Give 1st, 2nd and 3rd line antibiotic choices for mammalian bite wounds.

Back 155

1st line = Amox-clav.
2nd line - 2nd Gen ceph (cefuroxime).
3rd line - clindamycin plus cipro.

Front 156

Name 5 wound factors and 3 patient factors that make a wound high risk and thus require antibiotic prophylaxis.

Back 156

1. Puncture (cat bite), crush injury, older than 12 hours, hand and foot wounds, near a joint.
2. immunocomprimised, older than 50, prosthetic joint or valve.

Front 157

Name 5 wounds that are tetanus prone.

Back 157

Deep (>1cm), >6h old, crush, contaminated, bite

Front 158

1. Who should get Td with a wound?
2. Who should get TIG?

Back 158

1. No booster within the last 5 years.
2. No primary series get both Td and Tetanus immune globulin.

Front 159

1. What is the most common method of transmission of rabies to humans in North America?

Back 159

Bat bites - about 80%
In other parts of world it is domesticated animals such as cattle, horse, dogs and cats.

Front 160

Animal bite - Suspect Rabies
1. Describe management

Back 160

1. Contact public health
2. Rabies Immune Globulin 20IU/kg - inject as much as possible into the wound, then the rest into the other deltoid.
3. Rabies Vaccine (HDCV) - 5 1ml IM injection into deltoid at days 0, 3, 7, 14, 28

Front 161

Can Rabies Immune Globulin and Vaccine (HDCV) be used in pregnancy?

Back 161

YES!

Front 162

When should you initiate rabies prophylaxis in relation to a bat?

Back 162

1. Confirmed bite
2. found in room with sleeping person
3. found in room with child or baby
4. found in room with disabled person

Front 163

How should a fight bite be managed?

Back 163

1. High risk for septic arthritis and osteomyelitis.
2. X-ray skyline view of MCP
3. Debride and irrigate
4. Antibiotics for all - Amox-clav or cefuroxime
5. Immobilize hand with gauze dressing
6. Soak hand qid
7. If Sx of Infxn at presentation - IV antibiotics and surgical consult for OR debridement.

Front 164

Which of the following is NOT a common cause of CHF?
a) MI
b) Viral cardiomyopathy
c) Mitral stenosis
d) Aortic regurgitation

Back 164

c) Mitral stenosis *

Front 165

Name 6 common causes of CHF

Back 165

CAD, HTN, Valvular heart disease (not mitral stenosis), cardiomyopathies, pericardial disease, metabolic disorders (TSH), viral myocarditis, toxins

Front 166

Name 6 common causes of CHF exacerbation.

Back 166

1. Cardiac - MI, Ischemia
2.Meds - Non-compliance, B-blocker, CCB, NSAIDs
3. Increased Demand - anemia, infection, pregnancy, hyperthyroidism
4. Iatrogenic - fluid overload

Front 167

1. What is the difference between systolic and diastolic CHF?

2. What is the end result of both of these processes?

Back 167

Systolic - dilated left ventricle with impaired contractility and decreased cardiac output.
Diastolic - Increased ventricular stiffness and impaired relaxation leads to decreased filling leading to increased end-diastolic pressure.
Both lead to decreased renal blood flow and increased sodium and fluid retention and elevated left ventricle filling pressures leading to pulmonary edema.

Front 168

Name 2 causes of posterior shoulder dislocation.

Back 168

Rare - <5% of dislocations. Most common causes are electrocution and epilepsy.

Front 169

What % of adults will have an acute back pain episode?

Back 169

90% lifetime incidence

Front 170

What is the most common cause of back pain?

What is the natural course of this disorder?

Back 170

Lumbosacral strain and Sciatica

2. Benign and improves in 4-6 weeks without any interventions other than acetominophen and NSAIDs. Alternative therapy have no proven benefit.

Front 171

What are the 2 classes of SERIOUS non-traumatic back pain.

Back 171

1. SPINAL - cauda equina syndrome, spinal compression, epidural abcess, epidural hematoma, central disc herniation and osteomyelitis.

2. VASCULAR - Aortic dissection, AAA, PE, MI and retroperitoneal bleed.

Front 172

Name 8 RED FLAGS for back pain.

Back 172

1. Fever - infxn & cancer
2. Weight loss - cancer
3. Worse at night - cancer
4. IV drug use - infxn
5. Immunocompromised - infxn
6. History of Cancer - mets
7. Saddle anaesthesia - cauda equina
8. Neuro deficits - cauda equina
9. Anticoagulant use - epidural hematoma
10. Recent eipdural or spinal anaesthetic - epidural hematoma

Front 173

Name 4 symptoms that indicate back pain is more likely of a benign etiology.

Back 173

1. Worse with flexion
2. Worse with cough or Valsalva
3. Aching pain
4. Worse with movement

Front 174

Spinal Epidural Abcess
1. Description
2. Risk factors (5)
3. Symptoms (2) and Triad
4. Dx (4)
5. Tx

Back 174

1. An expanding suppurative infection in the spinal epidural space impinges on the spinal cord, producing sensory symptoms and signs, motor dysfunction, and, ultimately, paralysis and death
2. IV drugs, Prolonged corticosteroids, Immunocomprimised, epidural anaesthesia, diabetes.
3. Triad = Fever, back pain and neurological deficits. Sx = sphincter dysfunction, bladder retention
4. Loss of anal tone, bladder residual >200ml, X-ray (57% sens.), MRI is definitive.
5. IV Abx - Ceftriaxone + Ampicillen +/- vancomycin, Urgent neurosurg consult.

Front 175

Cauda Equina Syndrome
1. Define
2. Risk Factors (5)
3. Sx (5)
4. Dx (4)
5. Tx

Back 175

1. Compression of the spinal nerve roots of the cauda equina which begins at L1-2. It is a SURGICAL EMERGENCY.
2. Cancer, trauma, infection, sarcoidosis, ankylosing spondylosis,
3. Fever, chills, sweats, weight loss, Urinary or fecal incontinence, saddle anaesthesia, bilateral neurologic deficit
4. Loss of Anal tone, saddle anaesthesia, post-void residual >200ml (diagnostic), x-ray (60% sens.), MRI definitive.
5. IV Dexamethasone, IV opioids, urgent neurosurg consult.

Front 176

3 most common causes of surgical abdomen in the elderly.

Back 176

1. Cholecystitis
2. Bowel obstruction
3. Appendicitis

Front 177

1. Which ECG lead is best used to look at P waves?

2. Which direction will they normally be in this lead?

Back 177

1. Lead 2
2. Should be Upright

Front 178

Describe your approach to ECGs in the ER. (5)

Back 178

1. QRS - wide vs. narrow
2. Tachy vs. Normal vs. Brady
3. Rythm Regular or Irregular
4. P wave present?
5. Pulse or no pulse?

Front 179

Give 5 possible Dx of a wide QRS complex tachyarrythmia.

Back 179

1. VT
2. VF
3. A Fib
4. WPW
5. Torsades de pointes

Front 180

Give 4 DDx of a Narrow QRS bradyarrythmia.

Back 180

1. Sinus bradycardia
2. A Fib on meds
3. A Flutter on meds
4. 2nd Degree Mobitz type 2, (3rd degree block usually wide)

Front 181

Give 6 DDx of a Narrow complex QRS tachyarrythmia.

Which are irregular?

Which have P waves?

Back 181

1. A Fib - Irreg, no P
2. A Flutter - Usually Reg, P waves
3. SVT - Reg, No P wave
4. PSVT - Reg, No P wave
5. Sinus Tach. - Reg, P wave
6. Multifocal Atrial Tachy. Irreg, P waves.

Front 182

How are A Fib and Multifocal Atrial Tachycardia similar and different?

Back 182

Similar - Irregular, Narrow QRS, Tachycardia

Different - A Fib = No P wave. MAT = P wave

Front 183

Narrow complex QRS, Irregular, Rate 150, no P waves. Dx?

Back 183

Atrial Fibrillation

Front 184

Multifocal Atrial Tachycardia
1. Etiology
2. ECG findings
3. Tx

Back 184

1. Multple foci within the atria usually seen in severe hypoxia, theophylline overdose, hypoxia and most commonly in COPD exacerbation.
2. Irregular, Tachycardia, P waves, Narrow QRS, P waves all look different.
3. Slow rate with CCB (amiodarone), treat the cause (COPD, overdose).

Front 185

Which of the following is NOT a presentation of heat stroke?
a) severe CNS dysfunction
b) core temperature is greater than 41C
c) onset is gradual rather than sudden
d) the skin is hot and dry

Back 185

c) onset is gradual rather than sudden

Front 186

Pt. presents with decreased level of consciousness. On exam he has pinpoint pupils and is unresponsive. Which of the following is NOT a likely etiology?
a) cerebellar infarct
b) TCA overdose
c) morphine overdose
d) pons hemorrhage
e) ethanol overdose

Back 186

b) TCA overdose

Front 187

A 3 wk-old child presents to ED with unwell and decreased activity. He has episodes of bradycardia and apnea. On exam his RR is 20, HR 100, BP 60/?. He does have episodes of apnea but responds readily when stimulated. What would you do in the NEXT step of management?
a) intubate right away
b) jaw thrust, oxygenate with bag & mask, prepare to intubate
c) oral airway and give 100% oxygen
d) apply pulse oxymeter, if below 92% place oral airway and give 100% O2

Back 187

d) apply pulse oxymeter, if below 92% place oral airway and give 100% O2

Front 188

A 8y/o child has a Hx of Henoch-Schoenlein purpura (HSP) and presents with episodes of colicky and crampy abdominal pain. Which of the following must be ruled out?
a) appendicitis
b) volvulus
c) intussusseption
d) gastroenteritis

Back 188

c) intussusseption -

Front 189

Henoch-Schoenlein Purpura (HSP)
1. Etiology
2. Age of Presentation
3. Most common symptoms
4. Dx
5. Tx

Back 189

1. IgA mediated - likely an anaphylactoid
response to allergen (staph, virus, drug). Often precipitated by URTI.

2. 4 years of age +/- 2y.

3. Skin rashes (95.3%) & Fever - Erythematous macular rash on the lower extremities, 12-24 hours later the macules evolve into purpuric lesions that are dusky red and have a diameter of 0.5-2 cm. The lesions may coalesce into larger plaques that resemble ecchymoses.
-GI symptoms - Abdo pain, nausea, vomiting diarrhea and bloody stool, intessuception (72.0%)
-Joint involvement - Arthralgias (46.7%)
-Kidney involvement (28%) causes the most morbidity and mortality - hematuria, proteinuria - mesangial proliferation

4. Must differentiated from IgA nephropathy, which may present similarly. Leukocytosis, thrombocytosis, anemia, Proliferative glomerulonephritis, IgA deposition.

5. IV Fluids, Oral prednisone .5-mg/kg, azathioprine, IVIg.

Front 190

What is the TRIAD of Henoch-Schoenlein Purpura (HSP)

Back 190

puritic rash on lower extremities, abdominal pain and arthralgias. 50% of cases also have hematuria and cellular casts.

Front 191

A 10y/o boy fell and presented to another ED with a fractured wrist on X-Ray and was casted. He has been complaining of persistent pain overnight and on exam you notice his digits are swollen and slightly bluish in colour. He has good flexion but limited extension. What is you next step in management?
a) discharge and give ice and analgesics for pain and swelling
b) X-ray the wrist, remove cast if there is bone deformity or excessive soft tissue swelling
c) remove cast and examine the hand
d) urgent pediatric orthopedics consult

Back 191

c) remove cast and examine the hand - rule out compartment syndrome before calling pediatric ortho.

Front 192

Vagal Manoevres
1. Describe 3 types
2. Side effects from each and considerations
3. When would you use them?

Back 192

1. Carotid Sinus massage - apply pressure/massage the carotid at the angle of the jaw. Causes Vagal stimulation, decreasing heart rate and BP. Must rule out carotid bruit first. Used for A Fib, A Flutter, SVT (first line).
2. Valsalva manoevre - bear down - little risk and not very effective.
3. Rectal pressure - can cause syncope, make sure patient is flat.

Front 193

Give 3 treatments for SVT

Back 193

1. Vagal manoevre (carotid massage), Adenosine 6mg, Adenosine 12mg, then Synchronized cardioversion if no response.

Front 194

Ventricular Tachycardia (VT)
1. Describe ECG
2. Treatment with Pulse
3. Treatment without pulse

Back 194

1. Wide QRS, no P, tachy, usually regular.
2. ABCs, IV access, sedate, Sync Cardioversion, Amiodarone 150mg over 10 min.
3. 1 cycle of CPR, Shock immediately (200J biphasic or 360J mono), 1 cycle of CPR, check rhythm - Shockable? resume CPR - IV Epinephrine 1mg, CPR, Shock CPR Check Rhythm, CPR, Amiodarone 300mg or Lidocaine

Front 195

Name the contributing factors to VF/VT and Pulseless arrest that must be searched for during a code.

Back 195

6 H's and 5 T's
Hypovolemia, Hypothermia, Hypoglycemia, Hydrogen Ion Acidosis, Hypo/Hyperkalemia, Hypoxia.

Toxins, Tamponade, Tension Pneumo, Thrombosis (coronary or PE), Trauma

Front 196

Wolff-Parkinson-White
1. Etiology
2. Symptoms
3. Complications
4. ECG findings
5. Treatment

Back 196

1. Alternative conduction pathway that bypasses the AV node, resulting in early depolarization of the ventricle and a characteristic Delta wave.
2. Infants - arrhythmias = SOB, lethargic, stop eating, visible pulsations of the chest. Heart failure may develop.

Teens & 20s = sudden palpitations during exercise +/- syncope.

In older people, paroxysmal supraventricular tachycardia = fainting, SOB, chest pain.

3. Arrythmias - PSVT, A. Fib & VT

4. Delta wave

5. Treat arrythmia - VT = Amiodarone, PSVT = Adenosine, A Fib. = amiodarone. Treatment of WPW = Radiofrequency ablation.

Front 197

Atrial Flutter
1. ECG properties
2. Tx
3. Tx if unstable

Back 197

1. Narrow QRS, often regular, QRS rate around 150, P waves present and around 300, usually with a 2:1 or 3:1 block
2. Vagal manoevre, adenosine 6mg, 12mg then consider diltiazem if does not convert.
3. Unstable = immediate cardioversion

Front 198

Heart Block Properties and Tx
1. Normal PR interval
2. 1st Degree Block
3. 2nd Degree Type 1
4. 2nd Degree Type 2
5. 3rd Degree

Back 198

1. N = 0.12-0.2s
2. PR >0.2s, QRS after every P. no Tx
3. = Wenkebach - Progressively longer followed by dropped beat. Usually no Tx
4. Regularly dropped beat. Eventually will progress to 3rd degree - Tx = Stop Beta-blocker & CCB if unstable, definitive = Pacemaker
5. Complete AV dissociation - Tx = Stop all Beta-blockers/CCB, Put pacing leads on, pace if unstable, if doesn't work IV epinephrine drip, consider atropine or dopamine.

Front 199

Management of UNSTABLE 3rd Degree Heart Block

Back 199

1. Stop all Beta-blockers, CCB
2. Put pacing leads on
3. Pace if unstable,
4. If doesn't work IV epinephrine 1mg bolus or drip
5. If still unstable IV Atropine 1mg.
6. If still unstable IV Dopamine.

Front 200

1. What is a common cause of Heart Block?

2. Why?

Back 200

1. Inferior MI

2. Right coronary artery feeds the AV node

Front 201

Adenosine
1. Mechanism of Action
2. Indications
3. How to use it
4. Side effects that you need to tell patient

Back 201

1. Blocks AV node for 10-15s - loss of pulse/asystole by reducing cAMP and hyperpolarizing AV node cells.
2. Used in PSVT, SVT, Atrial Flutter, Ectopic Atrial Tachycardia
3. Try Vagal manoevre first. IV access must be close to heart - Antecubital. Push 6mg in seconds. Then try 12mg. If unsuccessful then Sync Cardioversion.
4. Warn patient they will have crushing chest pain for 10-20s. Warn staff that heart will FLAT LINE!

Front 202

1. What is the most common Post-MI thrombolysis Arrythmia with tKA?

2. Management

3. When else is this rhythm seen?

Back 202

1. Junctional Bradycardia

2. No treatment in reperfusion

3. Also seen with an Inferior MI due to loss of Right Coronary Artery perfusion to AV node.

Front 203

Which of the following is NOT a risk factor for developing frostbite?
a) ambient temperature
b) alcohol ingestion
c) loose clothing
d) diabetes

Back 203

b) alcohol ingestion *

Front 204

Which of the following is NOT part of the skill set of a primary care paramedic?
a) defibrillation
b) synchronous cardioversion
c) administer drugs such as nitroglycerin and epinephrine
d) transport trauma patients

Back 204

b) synchronous cardioversion

Front 205

Which of the following demographic groups pose the highest incidence of drowning?
a) teens and elderly
b) toddlers and teens
c) toddlers and elderly
d) teens and adults

Back 205

b) toddlers and teens

Front 206

Which of the following is TRUE for a bite wound?
a) culture swab must be performed on all wounds
b) culture swab must be performed in those wounds who show clinical signs of infection, such as erythema, swelling.
c) antibiotics must be given for wounds by cat bites
d) b) & c)

Back 206

d) b) & c)

Front 207

The responsibilities of a Base Hospital Physician include: (select 3)
a) administration of drugs
b) responsibility for an Delegated Medical Act performed by the Emergency Medical Attendant
c) providing on line assistance for Paramedics (EMA-III) when necessary
d) medical education of Ambulance Attendants
e) pronouncement of patients in the field
f) prioritization of ambulance calls
g) interpretation of the patient’s ECG rhythm strip

Back 207

b) responsibility for an Delegated Medical Act performed by the Emergency Medical Attendant *
c) providing on line assistance for Paramedics (EMA-III) when necessary *
e) pronouncement of patients in the field *

Front 208

Rapid neurologic evaluation of a comatose patient includes: (select 4)
a) otoscopic exam of tympanic membrane
b) Kernig’s and Bruzdinski’s signs
c) fundoscopic examination
d) peripheral motor/sensory examine by pain stimulus
e) determination of light touch and temperature sensation
f) cranial nerves II-XII
g) examine range of motion of neck and spine
h) Glasgow Coma Scale
i) speaking to family members/police etc. for ancillary history
j) expose patient and examine skin

Back 208

a) otoscopic exam of tympanic membrane *
c) fundoscopic examination *
f) cranial nerves II-XII *
h) Glasgow Coma Scale *

Front 209

Which are NOT features of exertional heat stroke? (select 2)
a) occurs in men 15-45 years of age
b) sweating usually present
c) rhabdomyolysis usually absent *
d) DIC marked
e) drug use common *
f) precipitated by heavy exertion

Back 209

c) rhabdomyolysis usually absent *

e) drug use common *

Front 210

A 45 y/o female is brought to the ED from an apartment fire. Select 4 clinical signs or symptoms consistent with CO poisoning.
a) cough
b) hoarseness
c) headache
d) nausea
e) confusion
f) fever
g) melena
h) hematuria
i) seizures

Back 210

c) headache *
d) nausea *
e) confusion *
i) seizures *

Front 211

What is the first thing you should do if you get an abnornally high potassium result on a pt.?

Back 211

Check the sample - was the sample hemolyzed. Redo the sample STAT!

Front 212

Name 4 common causes of Hyperkalemia in the ER

Back 212

1. Hemolysis - an artifact
2. Renal Failure - due to ACEI, NSAIDs, Potassium sparing diuretics and acidosis.
3. Cell death - burn, trauma, crush
4. Succinylcholine and digoxin - cause shift out of the cells

Front 213

Hyperkalemia.

1. PE Findings
2. Lab & ECG findings
3. Tx

Back 213

1. Weakness, cramps, focal neuro deficits.
2. K+ >5, ECG changes begin at >5.5. Peaked T waves --> Loss P waves --> Wide QRS --> prolonged PR --> Sine wave --> VF
3.
a. Heart - Calcium chloride 1 amp
b. Drive K+ into cells - Ventolin 4 puffs, 1 amp D50W with 10 U Humilin R, 1 amp HCO3
c. Excrete - Kayexelate, furosemide and dialysis if significant ECG changes.

Front 214

What common electrolyte and lab abnormalities are seen in pts. with renal failure?

Back 214

Azotemia = Accumulation of waste products.

Hyperkalemia, Anemia, Hyperphosphotemia, Uremia and increased BUN/Cr.

Front 215

Hyperkalemia
1. Treatment

Back 215

a. Heart - Calcium chloride 1 amp
b. Drive K+ into cells - Ventolin 4 puffs, 1 amp D50W with 10 U Humilin R, 1 amp HCO3
c. Excrete - Kayexelate, furosemide and dialysis if significant ECG changes.

Front 216

1. What percent of MI patients die before reaching the ER?

2. Name 3 sequelae of an MI

Back 216

1. 40%

2.
a. heart failure
b. dysrrythmias
c. cardiogenic shock

Front 217

What impact does thrombolytic therapy have on mortality?

Back 217

Decreases mortality by 25-50%

Front 218

1. Name 8 symptoms of an MI.

2. What symptom is most specific for an MI

Back 218

1. Retrosternal chest pain, diaphoresis, pain radiating to left or right arm, jaw pain, SOB, syncope, N + V

2. Pain radiating to R arm is more specific than to L arm.

Front 219

Which features of MI are more common in elderly?

Back 219

Dyspnea, Stroke, Syncope, Delerium, Weakness.

Pain is often not a presenting complaint compared to younger patients.

Front 220

Name 5 alternate diagnoses that must be ruled out when considering an MI.

Back 220

1. Aortic dissection - ripping/tearing to back
2. PE - SOB + pleuritic
3. Pericarditis - positional changes, pleuritic, distended JVP
4. Pneumonia - cough, sputum, SOB
5. AAA - epigastric, pulsatile

Front 221

Name 5 risk factors for MI.

Back 221

1. Previous MI
2. CAD
3. PVD
4. Smoking
5. DM2
6. Cholesterol
7. Male
8. Older
9. Family History of MI/Sudden Death.
10. HTN

Front 222

Name 7 PE features of an MI

Back 222

1. Decreased BP
2. Tachycardia
3. Increased JVP - RV Failure
4. Inspiratory crackles - LV Failure
5. S3 - LV Failure
6. Peripheral Edema - RV Failure
7. New systolic murmur - septal defect, papillary rupture, mitral regurg.

Front 223

Killip Class
1. How is it related to MI
2. Describe the 4 classes

Back 223

1. A classification of hemodynamic status.
a. Killip class 1 - well perfused, chest clear
b. Killip Pulmonary congestion - orthopnea, crackles
c. 3 - pulmonary edema, SOB, crackles
d. 4 - poor perfusion, cardiogenic shock

Front 224

Cover over the boxes and complete the following table regarding acid-base disorders and ABG interpretation.

Back 224

ABG Interpretation

Front 225

1. What ECG changes would prompt you to order a 15 lead ECG?

2. Which lead is most important and why?

3. What do the other leads tell you?

Back 225

1. 15 lead will give you a picture of the Right Ventricle. It should be done on all patients with an inferior wall MI (ST elevation in II, III and AVF).

2. V4R is the most important lead as it can diagnose a right ventricular MI.

3. V8-V9 give a picture of the posterior wall. Usually you see ST depression in the anterior leads V1-V6 so less informative than V4R.

Front 226

1. Where is an INFERIOR WALL MI seen on ECG?

2. What should you do if you see this type of MI?

3. What this information tell you?

ER Manual pg 42

Back 226

1. ST elevation seen in II, III and AVF

2. Order a 15 lead ECG to diagnose Right Ventricular Infarctions.

3. V4R can tell you if you have a Right ventriclar infarction. V8 and V9 look at the posterior wall infarction.

Front 227

Name 5 changes seen on ECG with an MI

Back 227

1. Increased voltage in R waves in precordial leads
2. Hyperacute T waves
3. ST segment elevation.
4. Q waves

Front 228

What ECG ST segment changes will be reflected in:
a. Inferior MI
b. Anteroseptal
c. Lateral
d. Anterolateral
e. Posterior

Back 228

a. II, III, aVF
b. V1-V3
c. I, aVL, V4-V6
d. V1-V6
e. ST depression in V1-V3, ST elevation in V8-V9

Front 229

How long does it take for Troponin levels to rise?

To peak?

Back 229

levels rise after 2-6 hours after onset of symptoms. Should do serial enzymes for 6-9 hours after presentation.

Peaks after 12-24 hours.

Front 230

Name 6 complications of an MI

Back 230

1. Arrythmia - most common cause of death
2. conduction blocks
3. LV failure and cardiogenic shock
4. Mechanical defects - rupture, VSD, papillary
5. Thromboembolism - prevent with heparin
6. Pericarditis - usually 5-7 days post-MI

Front 231

Name 4 key MEDICATION treatment priorities and their order in managing an MI

Back 231

1. ASA - 2-4 baby, chewed
2. Thrombolysis or PCI
3. Heparin or Enoxaparin
4. Clopidogrel

Front 232

describe your management of a patient presenting with a suspected MI.

Back 232

1. ABCs - O2, IV access, Fluids
2. Chew ASA - 2-4 baby
3. Nitroglycerine only if no Inferior MI (1/3 of MIs).
4. Stratify for Thrombolysis or PCI
5. Heparin or Enoxaparin
6. Morphine
7. Beta-Blocker - caution in inferior MI, asthma, COPD, heart block and hypotension/shock.
8. Clopidogrel - load 300mg, then 75mg/d

Front 233

When is thrombolysis (TKA) preferred over reperfusion (PCI)?

Back 233

Currently PCI is the preferred choice and should be given within 90 minutes. If not available, thrombolysis within 30 minutes.

Thrombolytics are most advantageous within the first 2 hours of symptom onset but can be used within 12 hours. Useless in cardiogenic shock. Also many contraindications.

PCI is most effective when given within 90 minutes of arrival. Also useful when symptoms are >3h old and in cardiogenic shock.

Front 234

Name 4 advantages of LMWH (enoxaparin or daltaparin) over unfractionated heparin.

Back 234

1. more predictable effect
2. no need for monitoring
3. lower rates of thrombocytopenia
4. better bioavailability

Front 235

Give 6 examples of when Beta-blockers be avoided in MI

Back 235

1. Inferior MI
2. Cardiogenic shock
3. CHF
4. COPD/Asthma
5. Hypotension
6. Blocks

Front 236

4 treatments for Methanol ingestion

Back 236

1. Ethanol if patient is allergic to fomepizole or not available

2. Fomepizole - competitive inhibitor of alcohol dehydrogenase

3. Folic acid - cofactor in metabolism of formic acid (toxin) to carbon dioxide.

4. Hemodialysis for refractory, significant ingestion, CNS and visual disturbances.

Front 237

A 50 year old street person comes into the ER after ingesting 50cc of methanol. He has abdominal pain and is feeling nauseas.

1. Describe your management and give 4 specific treatments for methanol poisoning.

2. Despite your medical treatment, he develops visual changes and decreased level of alertness. Management now?

Back 237

1. Ethanol if patient is allergic to fomepizole or not available.

2. Fomepizole - competitive inhibitor of alcohol dehydrogenase.

3. Folic acid - cofactor in metabolism of formic acid (toxin) to carbon dioxide.

4. Hemodialysis for refractory, significant ingestion, CNS and visual disturbances.

Front 238

Ethylene Glycol
1. Sources of the chemical
2. Clinical Signs of ingestion
3. Laboratory findings
4. Medical management

Back 238

1. antifreeze, laquers, detergents

2. Metabolized to aldehydes and oxylates, causing heart, lung and kidney toxicity.
a. No smell of EtOH, but Sx of intoxication
b. Stage 1 = Hallucinations, coma, seizures.
c. Stage 2 = Tachycardia, hypertension, ARDS, CHF
d. Stage 3 = Renal - flank pain, oliguria, calcium oxalate crystals in urine

3. Metabolic acidosis and Osmolal gap, calcium oxalate crystals in urine, serum ethylene glycol.

4. ABCs, Ethanol/Fomepizole, Pyridoxine and thiamine, correct hypomagnesemia. Hemodialysis for refractory cases.

Front 239

Give 3 test that give evidence of chronic alcohol ingestion.

Back 239

1. Elevated liver enzymes - especially GGT
2. Hyperchromic macrocytic anemia
3. Liver fibrosis on U/S

Front 240

How should a patient intoxicated with EtOH be managed in the ER?

Back 240

1. Neurovitals q1h
2. Saline lock IV - fluids usually not required
3. Monitor for seizures and failure to improve with time - suspect sudural if no improvement.
4. Serial EtOH levels are not useful
5. Administer Thiamine 100mg IM
6. D/C when alert, oriented and able to walk safely.

Front 241

How should EtOH withdrawal be managed?

Back 241

1. CIWA protocol
2. IV NS
3. Diazepam - 20mg q1h until features abate
4. Mutlivitamins
5. Thiamine 100mg IM

Front 242

Describe your management of Delerium Tremens.

Back 242

1. ABCs - consider sedation with propofol and intubation and monitored bed.
2. Diazepam
3. Barbituates
4. Thiamine
5. Correct glucose, electrolyte distubances

Front 243

Wernicke's Encephalopathy
1. Etiology
2. Clinical Features (5)
3. Tx

Back 243

1. Thiamine deficiency secondary to chronic EtOH abuse
2. Triad = Ataxia, confusion and nystagmus. May also include bilateral paralysis of Lateral rectus, ophthalmoplegia.
3. Thiamine 100mg IM until signs resolve, then 100mg PO for weeks.

Front 244

Pt. presents to ED suffering from multiple trauma. What is the minimal acceptable urinary output?
a) 100cc/hr
b) 60cc/hr
c) 50cc/hr
d) 30cc/hr

Back 244

d) 30cc/hr *

Front 245

Which of the following are at the highest risk of Tetanus wound infection? (Select 4)
a) wound of 12 hours duration
b) diabetics
c) crushed injury
d) injury to the extremities
e) HIV
f) Infected wound
g) Frostbite

Back 245

a) wound of 12 hours duration *

c) crushed injury *

e) HIV *
f) Infected wound *

Front 246

Which of the following are commonly used to manage near drowning survivors? (select 4)
a) supplemental oxygen
b) vigorous pulmonary suctioning
c) hypertonic saline
d) cardiac monitor
e) cardiac pacing
f) mechanical ventilation (if severe)
g) O2 saturation monitor

Back 246

a) supplemental oxygen *
b) vigorous pulmonary suctioning
c) hypertonic saline
d) cardiac monitor *
e) cardiac pacing
f) mechanical ventilation (if severe) *
g) O2 saturation monitor *

Front 247

Which age groups have the highest risk of drowning?

Back 247

Toddlers and teens

Front 248

Name 6 risk factors that contribute to drowning

Back 248

1. toddlers and teens
2. alcohol and drugs
3. risk taking
4. hyperventilation - lead to hypoxia
5. trauma while swimming/diving
6. leaving children unattended -abuse/neglect

Front 249

Give 6 reasons why hypoxemia results from near-drowning.

Back 249

1. loss of surfactant leads to atelectasis
2. pulmonary edema ensues
3. proteins leak into alveoli
4. small airway obstruction with water and particulates
5. bronchospasm
6. aspiration leads to pneumonitis
7. Dry-drowning due to laryngospasm

Front 250

Define Dry-Drowning

Back 250

Aspiration of water leads to laryngospasm and respiratory failure without water entering the lungs.

Front 251

Name 7 investigations that should be done in all near-drowning patients.

Back 251

1. CXR
2. ABG
3. CBC
4. Lytes
5. Cr, BUN
6. INR/PTT
7. ECG

Front 252

Give 5 treatments for a near drowning.

Back 252

1. Oxygen by face mask or BiPAP
2. Intubate early for protection and pulmonary toilet
3. C-spine protection if indicated
4. IV fluids for hypotension
5. Correct hypoglycemia and electrolytes

Front 253

If a woman discloses that she is being abused, it is often very helpful to: (select 4)
a) let her know that you are glad she could tell you about it
b) be supportive and non-judgmental
c) discuss the behaviour with the abuser so that he can change
d) contact Police even if the woman doesn’t want to so that they can provide help
e) provide her with a list of local resources for abused women
f) discuss issues related to her immediate safety

Back 253

a) let her know that you are glad she could tell you about it *
b) be supportive and non-judgmental *
c) discuss the behaviour with the abuser so that he can change
d) contact Police even if the woman doesn’t want to so that they can provide help
e) provide her with a list of local resources for abused women *
f) discuss issues related to her immediate safety *

Front 254

A 9 mo. old boy arrives in your ED with a barking cough and stridorous breathing which woke him up 2 hours ago from his sleep. RR=50, HR=120, T=38.5C, chest retractions present. He vomited twice in the car on the way to the hospital. Your first step is to provide the child with humidified oxygen. The child remains very stridorous at rest and the vital signs remains unchanged. You now: (select 2)
a) give inhaled ipratropium
b) give inhaled salbutamol
c) give oral corticosteroids
d) give inhaled racemic epinephrine
e) consider intubation

2. What is the Dx?

3. What is the causative organism?

4. What was wrong with the initial management?

5. What dosages should you prescribe.

Back 254

1.
c) give oral corticosteroids *
d) give inhaled racemic epinephrine *

2. Laryngotracheobronchitis (Croup)

3. Parainfluenza virus

4. Humidified O2 has not been shown to be effective with croup.

5. Dexamethasone - 1mg/kg po - go to IV if no response. Nebulized Epinephrine 1:1000 2.5ml - follow for at least 2h after administration - short half life.

Front 255

A 60 day old infant presents to ED unwell and decreased oral intake. Based on the Rochester Criteria, which of the following would you ask the mother:

a) GA at birth (term or preterm)
b) Previous hospitalizations
c) Duration of stay at hospital after birth
d) Hx of hyperbilirubinemia
e) Hx of Abx
f) Hx of chronic illness

Back 255

All the above

Front 256

Which of the following can you administer via an ETT? (Select 4)
a) ipratropium bromide
b) salbutamol
c) adenosine
d) epinephrine
e) lidocaine
f) atropine
g) naloxone
h) theophylline

Back 256

NAVEL

b) salbutamol *
d) epinephrine *
e) lidocaine *
f) atropine *
g) naloxone *

Front 257

A G2P2 female presents with 2 day Hx of RLQ pain. Her LMP was 2 wks ago and she’s known to have irregular periods. She has not noticed any vaginal bleeding. Select 4 most likely differential diagnoses:
a) hepatitis
b) ectopic pregnancy
c) diverticulitis
d) ovarian cyst rupture or torsion
e) pelvic inflammatory disease
f) appendicitis
g) cholecystitis
h) uterine fibroids
i) endometriosis

Back 257

a) hepatitis -no Hx to suggest
b) ectopic pregnancy *
c) diverticulitis - more likely in >50
d) ovarian cyst rupture or torsion *
e) pelvic inflammatory disease *
f) appendicitis *
g) cholecystitis - with meals, on and off pain
h) uterine fibroids - with periods, heavy bleeding
i) endometriosis - with periords, heavy bleeding

Front 258

10 features that can increase scarring when a laceration is sutured.

Back 258

1. Leaving devitalized tissue
2. Knots are too tight
3. Using reactive sutures such as silk or cat gut
4. poor apposition
5. failure to remove stitches in a timely manner
6. Skin type - dark skin = increased keloid
7. Type of laceration - crush is worst
8. crosses skin creases
9. Infection
10. Protect from sun

Front 259

1. 4 time dependent, essential items for treatment in sexual assault.

2, Describe how you would treat each.

Back 259

1. Pregnancy - 2 Ovral tablets orally q12h or 2 tabs plan B STAT.
2. STD - cefixime 400mg once + doxy 100mg bid x 7d OR Azythromycin 1g once +/- Ceftriaxone 400mg IM
3. Hep B - HIG + Hep Vaccination if not immune
4. HIV - start regimen within 72 if patient wishes or vaginal/anal trauma, high risk offender

Front 260

What is the upper time limit for primary wound closure with a laceration?

Back 260

6-8 hours

Front 261

A palliative patient has been using 25mg of hydromorphone in a 24 hour period. What should his breakthrough dose be?

Back 261

1/10th of 24h dose, or 2.5mg.

Front 262

1. A palliative patient presents to the ER in an acute pain crisis and takes 360mg of morphine a day. What should his initial dose be?

2. Anything else you can offer?

Back 262

1. 1/10th daily dose = 36mg IV!

2. Midazolam 2-4mg IV will reduce anxiety and improve pain control.

Front 263

You prescribe a patient a 4mg q4h hydromorphone dose for acute cancer pain. what should the breakthrough dose be?

Back 263

2mg q1h (50% of q4h dose).

can also calculate - 4mg q4h x 6 = 24mg q24h /10 = 2.4mg.

Front 264

Nausea and Vomiting

Give 2 medications for each of the following situations and why they work best.

1. Post-chemo
2. Post abdo surgery
3. Metastatic colon cancer with bowel obstruction
4. Morphine

Back 264

1. Chemo acts at the N+V center via 5HT3 - use odansatron 8mg IV q8h
2. Abdo damage releases 5HT3 - use odansatron
3. Bowel distention releases dopamine. Use dopamine antagonists - Prochloperazine (10mg IV q6h), haloperidol 1mgIV q4h or metochlopramide 10mg IV q4h\
4. gravol works well for morphine

Front 265

Give a stepwise approach to management of constipation.

Back 265

START from below and then from above.

1. Enema - tap water
2. Manual dispempaction
3. Lactulose - osmotic
4. Magnesium citrate
5. Polyethylene glycol - Golytlely
6. Prophylaxis - Senna and bisacodyl

Front 266

Give 4 treatments for acute delerium.

Back 266

1. control the environment - clocks, lights, noises
2. Rule out disease - UTI, pneumonia, MI, CVA
3. Haloperidol 1-2 IV
4. Lorazapam 2-5mg IV

Front 267

1. Name 2 treatments for the death rattle.

2. What should you not do?

Back 267

1. Scopolamine 0.6mg SC q4h prn or glycopyrrolate 0.6mg SC q4h prn.

2. Avoid suctioning - uncomfortable and invasive and can upset dying patient.

Front 268

You are assessing and resuscitating a trauma patient with your mentor. Things are going well, when, just as you being the secondary survey, the patient begins to deteriorate. The FIRST thing that should be done is to: (1 mark)

Back 268

* Airway, breathing, circulation

Front 269

What is the minimum systolic blood pressure required to produce a palpable pulse in the following areas (3 marks)
Carotid
Femoral
Radial

Back 269

Carotid: 60
Femoral: 70
Radial: 80

Front 270

1. A 49 y/o male with a strong family history of coronary artery disease presents with retrosternal chest pain of 2 hours duration, associated with diaphoresis and dyspnea. His ECG in the ER is normal, and a CK & CK-MB done on arrival is negative. Can one reasonably rule out a myocardial infarction in this patient at this point? (1 mark)

2. Make at least 2 points as to why or why not. (2 marks)

Back 270

1) Troponin, CK & CK-MB rises above normal at least 6 hrs post MI - first test may be normal.

2) Presenting EKG may show NQWMI or no changes. Need to do serial ECGs.

Front 271

What is the best way to diagnose hypothermia? (1 mark)

Back 271

Esophageal is the best measure, while Rectal temperature is more practical and more accurate than tympanic.

Front 272

Define hypothermia

Back 272

core body temperature <35 on rectal temp.

Front 273

What types of heat loss contribute to hypothermia and what % do they involve in heat loss?

Back 273

1. Radiation - 55%
2. Evaporation - 30%
3. Conduction - 15% - significant in immersion
4. Convection - very minor role, except in very cold & windy env.

Front 274

Give 6 risk factors for hypothermia

Back 274

1. Elderly, very young
2. Altered MS - alcoholics and MS altering drugs
3. Acute illness
4. Decreased fat/muscle
5. immersion in cold water
6. peripheral or autonomic neuropathy (DM2).

Front 275

Describe 6 symptoms of hypothermia (core temp <32).

Back 275

1. Confusion, lethargy
2. Shivering
3. J (osborne) waves on ECG
4. Tachypnea
5. Sinus bradycardia -> A Fib -> V Fib
6. Decreased peripheral pulses

Front 276

1. Why must you not rewarm the peripheral body in hypothermia?

2. How should you rewarm?

Back 276

1. Peripheral rewarming leads to cold blood being recirculated to the heart and leads to fatal arrythmias - AFTERDROP.

2. Apply heating blankets, extracorporeal shunts and warm fluids to the core only.

Front 277

Briefly discuss the conditions which must be met for an Emergency Physician to administer treatment to a patient without the patient’s consent: (2 marks)

Back 277

* 1) Patient is incapable of consent and no SDM is available
* 2) Situation is emergent, pt. is incapable of consent and delay to obtain consent from SDM will jeopardize pt.’s life.

Front 278

47. Pt. presents with severe headache lasting the past few days. What are the possible positive findings on CT? (4 marks)

Back 278

* extradural hematoma
* subdural hematoma
* subarachnoid hemorrhage
* concussion/cerebral contusion

Front 279

Pt. presents with severe pulmonary edema. What 2 adjunctive measures can be given in addition to medications (2 marks)?

Back 279

* CPAP / Bi-PAP / PPV
* Intubation and ventilation if resp. failure or airway obstruction
* Phlebotomy or hemodilution

Front 280

Pt. presents with severe asthma and respiratory distress. List the steps of management, starting with where to place the pt. in the emergency room, and specifically how you will monitor the pt. (10 marks)

Back 280

1. Place pt. in acute area or resus if space available
2. ABC (ensure A/W is clear, 100% O2 by mask, large bore IV & fluid resuscitation)
3. Place pt. on monitor (BP, HR, EKG, RR, SaO2)
4. Ventolin and Atrovent via MDI with spacer -
5. After 1 hour of Salbutamol consider Administering K+
6. IV steroids for all exacerbations - methylprednisone 125mg IV
7. Refractory? IV Magnesium 2g over 2 min
8. IV Salbutamol
9. If you reach this stage intubate and run continuous Inhaled salbutamol
10. Succinylcholine 1.5mg/kg IV push and Ketamine 1.5mg/kg over 30s.

Front 281

A chronic alcoholic presents to ED complaining of tachypnea. He was found to be in no respiratory distress and has no other complaints. Laboratory investigations are as follows:
pH 7.32 HCO3 21
Na 141 BS 7.1
Cl 100 Cr 72
K 4.7 BUN 9

1. Calculate anion gap
2. Calculate osmolal gap.
3. List the conditions that can cause an elevated anion gap.
4. What conditions can cause an anion and osmolal gap acidosis?
5. What is a normal anion gap?
6. List 4 conditions that are likely to cause an anion gap in THIS PATIENT.

Back 281

1. AG = Na - (Cl + HCO3) =20 (normal = <10)

2. OG = 2x141 + 7.1 + 9 = 298 (2 salts, a sugar and a BUN). Normal OG = -14 to +10

3. Causes of increased AG acidosis = MUDPILES - Methanol, Uremia, DKA, Propylene glycol, Isopropyl, Lactic, Ethylene, Salicylate

4. Increased Osmolal gap - Ethylene glycol, Isopropyl alcohol, Glycerol, Mannitol, Methanol, Sorbitol

5. <10

6. DKA, Methanol, Ethylene glycol, Isopropyl, Salicylates

Front 282

How do you calculate:

1. Anion Gap
2. Osmolal Gap
3. What are normals?
4. What can you deduce from this info?

Back 282

1. Na - (Cl + HCO3)

2. 2 salts, a sugar, a BUN and a drink = 2 x Na + BS + BUN + EtOH. Subtract from measured osmolal gap.

3. AG should be <10. OG should be between -14 and +10.

4. Elevated AG = MUDPILES. Elevated OG = Methanol, Isopropyl, ethylene glycol, mannitol, sorbitol

Front 283

MUDPILES and Anion Gap. Give the words for the acronym.

Back 283

Methanol, Uremia, DKA, Polyethylene glycol, Isopropyl, Lactic, Ethylene glycol, Salicylates

Front 284

Regarding shoulder dislocation:
a) What is the most common presentation? (1 mark)

b) Which nerves are at the most risk of injury and which anatomical location do they supply? (2 marks)

c) What are the 2 ways to manage this patient? (2 marks)

d) What would you advise to the patient upon discharge? (2 marks)

Back 284

a. * anterior

b. * axillary nerve supplies the deltoid and musculocutaneous supplies surrounding skin

c. Need ++ sedation and pain meds
1) passive weight-driven reduction with a 10lb weight in prone position - Stimson;
2) traction-countertraction w/ 2 people

d. * X-ray to rule out fracture, ice, analgesics & anti-inflammatory meds, F/U with GP, referral to orthopedic surgeon, return to ED if neuro/vascular Sx develops.

Front 285

1. Mechanism of action of penicillen and cephalosporins.

2. Bacterialcidal or Bacteriostatic?

Back 285

Both are bacteriacidal Beta-lactams and inhibit cell wall synthesis. Cephalosporins are more resistant against penicillenases.

2. Bacteriacidal

Front 286

1. Mechanism of action of aminoglycosides.

2. Bacterialcidal or Bacteriostatic?

Back 286

Inhibit protein synthesis by binding to the 50S or 30S ribosomal subunit.

2. Bacteriostatic

Front 287

1. Dx
2. Tx

Back 287

Front 288

1. Dx
2. Tx

Back 288

Front 289

1. Dx
2. How would you manage this rhythm?

Back 289

Front 290

1. Dx
2. Tx

Back 290

Front 291

1. What is the diagnosis?
2. How would you manage her?
3. What is the time window for your planned intervention?
4. Would you manage her differently if she present with these symptoms for the last 5 days?

Back 291

Front 292

Back 292

Front 293

Back 293

Front 294

Back 294

Front 295

1. Give 3 clinical signs of an upper airway obstruction.

2. Give 2 conditions that would cause these sings.

Back 295

1. a) drooling
b) “hot potato” voice
c) stridor

2. Epiglottitis (Hib) and Croup (Parainfluenza)

Front 296

1. A 27 year-old man is brought into the ER after a bicycling accident. A car door suddenly opened in front of him, of which he smashed into and was thrown 15 feet. On examination, he is drowsy and confused. He opens his eyes when his name is called. He mumbles words that you understand but the sentences do not make sense. He moves all four limbs but does not respond to any commands. He is able to pull both hands away when pinched and squirms when his sternum is rubbed, making no effort to stop you. What is his Glasgow COMA Scale score?
10
11
9
8
7

Back 296

10
4 - Eyes
5 - Verbal
6 - Motor

Front 297

Which of the following are not consistent with primary (spontaneous) bacterial peritonitis?
a. Abdominal discomfort and fever
b. Ascitic fluid neutrophil count of> 250x10(6) cells/L
c. Ascitic fluid WBC count of >500x10(6) cells/L
d. Multiple organisms on culture and sensitivity of ascitic fluid

Back 297

d. Multiple organisms on culture and sensitivity of ascitic fluid

Front 298

Prolonged vomiting is associated with what electrolyte abnormality?
Hypochloremic hypokalemic metabolic acidosis
Hypochloremic hypokalemic metabolic alkalosis
Hyperchloremic metabolic acidosis
Hyperkalemia
None of the above

Back 298

Hypochloremic hypokalemic metabolic alkalosis

Front 299

A 25 year-old known substance abuser is brought to the ED with a suspected overdose. Which of the following is not considered a universal antidote?
Glucose
Oxygen
Calcium gluconate
Naloxone
Thiamine

Back 299

Calcium gluconate - although useful for cardioprotection in hyperkalemia

Front 300

Give the numbers for GCS

Back 300

Front 301

A 37 year-old male arrives at the Emergency Department unconscious. He is warm and sweaty. His heart rate is 52 bpm, his BP is 90/60. His pupils are constricted, his eyes are teary, and he is drooling. You assume he is suffering from a toxidrome.

1. What is the toxidrome?
2. Name 3 possible toxins that cause this.
3. Pick 2 antidotes that you will give him.
Flumazenil
Naloxone
Glucagon
Atropine
Ethanol
2-Pam

Back 301

1. Cholinergic - salivation, lacrimatin, incontinence, diarrhea, bronchorrhea, bradycardia.

2. Organophosphates, carbmates and nerve gas.

3. Atropine and 2-Pam

Front 302

A 16 year-old girl is brought to hospital by her frantic parents after a bee sting. Vitals signs are BP 70/40, RR 30 and laboured, HR 140, T 37.5. Which of the following would not be an option in her management?
Epinephrine
Diphenhydramine
Methylprednisolone
Salbutomol
Atropine

Back 302

Atropine - it will increase heart rate

Front 303

Tension pneumothorax is best diagnosed with:
Stat CT scan
Chest x-ray
Watch and wait
Clinical exam
None of the above

Back 303

Clinical exam & needle thoracostomy

Front 304

A patient presents with decreased level of consciousness. On exam he has pinpoint pupils and is unresponsive. Which of the following is NOT a likely etiology?
Cerebellar infarct
TCA overdose
Morphine overdose
Pons hemorrhage
Ethanol overdose

Back 304

TCA overdose - Causes an anticholinergic toxidrome - Dilated, Dry, Red, Hot.

Front 305

How do you assess a patient that presents to the ED? When do you restart this assessment?

Back 305

Airway/C-spine, Breathing, Circulation, Disability, Environment/Exposure. Restart when conditions deteriorates.

Front 306

How does consent change in the context of Emergency Medicine (EM)?

Back 306

Consent is not needed when patient is at imminent risk from serious injury AND obtaining consent is not possible.

Front 307

What is the Cushing’s reflex?

Back 307

Sign of increased ICP: high BP, low HR, irregular respirations

Front 308

What are the universal antidotes in EM?

Back 308

Oxygen, glucose, naloxone, thiamine

Front 309

What should every patient with an MI receive?

2. Are there contraindications to some of these treatments?

Back 309

1. ASA chewed - 160mg
2. Tenektaplase or PCI
3. Enoxaparin
4. Clopidogrel

In ER also “BEMOAN”: Beta-blockers, Enoxaparin, Morphine, Oxygen, ASA, Nitroglycerin.

Caution with B-blocker in inferior MI, COPD, Asthma, CHF.

Front 310

What are the signs of a basal skull fracture?

Back 310

Battle sign, hemotympanum, racoon eyes, CSF otorrhea/rhinorrhea

Front 311

Shock in a trauma patient is ____ until proven otherwise?

Back 311

Hemorrhagic

Front 312

Level of consciousness is assessed using what scale?

Back 312

GCS or AVPU

Front 313

At what GCS should you intubate?

Back 313

8 or less

Front 314

Name 1 KEY investigation for a potential spinal cord trauma patient?

Back 314

C-spine X-rays with 4 views - AP, Lat, Swimmer and Odontoid

Front 315

What is the management of a tension pneumothorax?

Back 315

11. Large bore IV needle inserted into 2nd ICS mid-clavicular line, followed by chest tube in 5th ICS ant-axillary line

Front 316

What imaging modalities should be considered in abdominal trauma?

Back 316

FAST, DPL, X-ray, CT

Front 317

For penetrating trauma, when is laparotomy mandatory?

Back 317

Shock, peritonitis, evisceration, free air, gunshot, blood in NG, Foley, or on DRE

Front 318

What are the contraindications to a Foley catheter?

Back 318

Blood at the urethral meatus, ecchymosis of the scrotum, “high riding” prostate

Front 319

What nerves are at risk with an anterior shoulder dislocation?

Back 319

Axillary nerve (lateral), and musculocutaneous nerve (extensor aspect of forearm)

Front 320

When is an X-ray series of the ankle required?

Back 320

Any pain in the malleolar zone AND tenderness in either malleolar zone OR inability to weight bear

Front 321

When is an X-ray series of the foot required?

Back 321

Any pain in the midfoot zone AND Tenderness at the navicular or 5th metatarsal OR inability to weight bear

Front 322

1. What is the maximum dose of subcutaneous lidocaine that can be given with and without epinephrine?

2. How about bupivicaine?

3. How many mg/ml does 1% lidocaine have? 2%?

4. Calculate the maximum dose of lidocaine with epi for a 50kg male.

Back 322

1. 7 mg/kg with epinephrine, 5 mg/kg without epinephrine

2. 3mg/kg with, 5mg/kg without.

3. 1% has 10mg/ml, 2% has 20mg/ml

4. 1% lidocaine has 10mg/ml. max dose for 50kg is 5x50 = 250mg. Max = 25cc.

Front 323

Where should lidocaine with epinephrine NOT be used?

Back 323

Ears, nose, fingers, toes, and hose (penis)

Front 324

What is the most commonly used antibiotic for cellulitis?

Back 324

Cefazolin/Ancef (IV) and Cephalexin/Keflex (PO)

Front 325

What is the first line antibiotic for human bites?

Back 325

Amoxicillin + clavulinic acid

Front 326

What are the 2 leading causes of death in the age group of 1-44 y/o?

Back 326

1. Trauma
2. Suicide

Front 327

When do the majority of deaths occur in trauma? What is our goal in trauma resuscitation/

Back 327

In the first hour, in the field. These are the unsalvageable. Our goal is to reduce the early deaths in the first 4 hours or the "Golden Hour".

Front 328

Describe the GENERAL approach to assessment and resuscitation of the trauma patient.

Back 328

1. Primary Survey - ABCDE
2. Resuscitation
3. Secondary Survey - Head to Toe - fingers and tubes in every orifice.
4. Investigations
5. Definitive care

Front 329

Describe the step-wise approach to management of an airway in a trauma patient.

Back 329

1. Chin lift
2. Suction
3. Oral/Nasal airway
4. ETT
5. Laryngeal mask
6. Surgical airway

Front 330

Tension Pneumothorax
1. Clinical Signs (6)
2. Tx

Back 330

1.
a. Absent breath sounds on one side,
b. trachea deviated away,
c. distended neck veins,
d. pulseless electrical activity,
e. difficult ventilation
f. decreased SaO2

2.
a. Immediate needle thoracostomy with 14 gauge needle in 2nd intercostal space, mid-clavicular line
b. Chest tube place at 5th intercostal space, mid-axillary line.

Front 331

Name 6 clinical features that you can monitor to evaluate for shock.

Back 331

1. Level of consciousness
2. HR
3. BP
4. RR
5. Urine output
6. Cap refil
7. Skin colour

Front 332

Name the potential causes of shock.

Back 332

SSHOCK
Septic
Spinal
Hypovolemia - blood
Obstructive - PTX, tamponade
Cardiogenic
K- anaphalactic

Front 333

How can you manage an open book fracture of the pelvis in the ER?

Back 333

Wrap a bedsheet around the patient and tie tight. This will tamponade the amount of blood that can collect in the pelvis.

Front 334

A patient was invovled in a car accident 30 minutes ago. The FAST shows a splenic rupture and he is now hypotensive.
1. What fluids will you give him.
2. What if he doesn't respond?
3. What type of blood would he get?

Back 334

1. 2L blous of NS
2. Failure to respond to 2L NS requires the addition of more NS and pRBCs.
3. Females under 50 get O-, all others get O+.

Front 335

What does AVPU mean?

Back 335

Used in place of GCS in trauma patients.
Alert
Responds to Verbal
Responds to Pain
Unresponsive

Front 336

What is the single most important radiology investigation in the trauma patient? Second?

Back 336

CXR
FAST

Front 337

Give 6 indications to send a trauma patient directly to the OR.

Back 337

1. Evisceration
2. Amputation
3. Peritonitis
4. Expanding abdomen
5. Blood per rectum/in NG tube
6. Hemorrhage with hypotension.

Front 338

Give 3 signs of a basal skull fracture.

Back 338

1. racoon eyes
2. nasal CSF leak
3. bruising behind ears

Front 339

Give 3 contraindications to an NG tube.

Back 339

1. Suspected basal skull fracture
2. Facial bones smashed
3. penetrating neck trauma

Front 340

Describe the features that you need to see on X-Ray to clear a c-spine (5).

Back 340

Think General and ABCD

1. Need 4 views - AP, Lateral, Swimmers and Odontoid and need to see down to T1

2. Alignment - Anterior, Posterior and spino laminar lines are C shaped.

3. Bones - examine each vertebrae and the soft tissue in front - should be no more than hilf the width of the vertebrae.

4. Cartillage space - should be equal

5. Dens - need to ensure that the dens is intact via odontoid view

Front 341

Describe your approach to Pulseless Electrical Activity and Asystole

Back 341

ABCs, 6H's and 5T's

2 minute cycles of CPR-rhythm checks and think:

P E A
P - Problem search. Treat accordingly. Continue this algorithm if indicated.

E - Epinephrine 1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi.

A - Atropine 1 mg IV/IO q3-5 min. (3mg max.)

Front 342

Describe your approach to bradycardia with circulatory compromise.

Back 342

ABCDs and:

*Pacing Always Ends Danger

Pacing **TCP Immediately prepare for transcutaneous pacing (TCP) with serious circulatory compromise due to bradycardia (especially high-degree blocks) or if atopine failed to increase rate.
Consider medications while pacing is readied.

Always Atropine 1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg)

Ends - Epinephrine 2-10 µg/min 2nd-line drugs to consider if atropine and/or TCP are ineffective. Use with extreme caution.

Danger - Dopamine 2-10 µg/kg/min

*Pacing does not "always end danger" in bradyarrhythmias. If the above measures do not improve circulatory stability the bradycardia may merely be an indication of a pathological process, think Differential Diagnosis!

Front 343

1. What are the indication for Synchronized Electrical Cardioversion?

2. What equipment do you need ready?

Back 343

Synchronized electrical cardioversion is performed on unstable tachycardias with circulatory compromise due to the fast rate

2. Oh Say It Isn't So

Oh - O2 Saturation monitor
Say - Suctioning equipment
It - IV line
Isn't - Intubation equipment
So - Sedation and possibly analgesics

Front 344

When would you perform Unsynchronized Electrical Cardioversion?

Back 344

Give unsynchronized shocks at VF/PVT energy levels without delay for unstable tachycardia with critical circulatory compromise due to the fast rate - VT/VF. Also give unsynchronized shocks if you cannot synchronize, or if polymorphic VT is present.

If VF/PVT develops, immediately defibrillate at *360J per the VF/PVT Algorithm *Or biphasic equivalent of 200J.

Front 345

How should you approach a stable, narrow, regular tachycardia?

Back 345

1. Stable? Yes
↓ next question No, unstable = Immediate electrical cardioversion

2. Narrow? Yes
↓ next question No, wide = Consult an expert
(QRS ≥0.12 sec)

3. Regular? Yes
↓ see mnemonic No, irregular = Consult an expert

Yes 1-2-3, think SVT, then V-A-C
↓
Vagal maneuvers, if this fails..
↓
Adenosine 6mg rapid IV push
(may repeat x2, q1-2min. at 12mg)
↓
Cardizem (diltiazem) managed by an expert if
stable, narrow, regular tachyarrhythmia continues

Front 346

1. Give a DDx for the following rhythms.

2. Give 2 treatments for each.

1. Narrow Irregular Tachycardia
2. Narrow Regular Tachycardia
3. Wide Irregular Tachycardia
4. Wide Regular Tachycardia

Back 346

1. Narrow Irregular Tachycardia
a. Atrial Fibrillation, Multifocal Atrial Tachycardia, possibly Atrial Flutter
b. If less than 12 hours consider amiodarone or sync cardiovert. Otherwise Rate Control: diltiazem or beta blocker + anticoagulant.

2. Narrow Regular Tachycardia
a. Recurrent SVT, Atrial Flutter, Junctional or Ectopic Atrial Tachycardia
b. Vagal manoevres, adenosine and cardioversion for SVT. Rate Control for others: diltiazem or beta blocker.

3. Wide Irregular Tachycardia
a. Torsades, VF, VT
b. Cardioversion, Amiodarone and epinephrine. (Avoid calcium channel blockers and digoxin due to possible AF+WPW)
b. Consider amiodarone.
c. Magnesium 2g IV over 5min. for torsades

4. Wide Regular Tachycardia
a. If VT, amiodarone 150mg IV over 10min. repeat prn (max 2.2g IV/24hr)
b. elective synchronized cardioversion

Front 347

Describe the Ventricular Fibrillation (VF)/Pulseless Ventricular Tachycardia (PVT) Algorithm

Back 347

SCREAM

S - Shock
360J* monophasic, 1st and subsequent shocks.
(Shock every 2 minutes if indicated)

C - CPR
After shock, immediately begin chest compressions followed by respirations (30:2 ratio) for 2 minutes. (Do not check rhythm or pulse)

R - Rhythm
Rhythm check after 2 minutes of CPR (and after every 2 minutes of CPR thereafter) and shock again if indicated. Check pulse only if an organized or non-shockable rhythm is present.

Implement the Secondary ABCD Survey. Continue this algorithm if indicated. Give drugs during CPR before or after shocking. Minimize interruptions in chest compressions to <10 seconds. Consider Differential Diagnosis.

E - Epinephrine
1 mg IV/IO q3-5 min. Or vasopressin 40 U IV/IO, once, in place of the 1st or 2nd dose of epi.

A
M
Antiarrhythmic Medications

Consider antiarrhythmics. (Any Legitimate Medication)

Amiodarone 300mg IV/IO, may repeat once at 150mg in 3-5 min. if VF/PVT persists or

Lidocaine (if amiodarone unavailable) 1.0-1.5 mg/kg IV/IO, may repeat X 2, q5-10 min. at 0.5-0.75 mg/kg, (3mg/kg max. loading dose) if VF/PVT persists,or

Magnesium Sulfate1-2 g IV/IO diluted in 10mL D5W
(5-20 min. push) for torsades de pointes or suspected/ known hypomagnesemia.

Front 348

Hypercalcemia
1. Causes (6)
2. Clinical Features (5)
3. ECG Changes (2)
4. Dx (2)
5. Tx (4)

Back 348

1.
a. Malignancy, Malignancy, Malignancy
b. Hyperparathyroidism
c. Calcium and Vit D supplementation
d. Dehydration
e. acromegaly
f. Acute or Chronic Renal Failure

2. Stones (Nephrolithiasis), Bone pain, Abdominal groans, Psychic overtones (depression, hallucinations), Hypotonia

3. QT prolongation and arrythmias

4. Ca+ (corrected for albumin), renal function and ECG.

5. IV FLUIDS most important - most are dehydrated.
b. Furosemide to get them to pee it out once hydrated.
c. Calcitonin - prevents reabsorption in distal tubule
d. Bisphosphonates - drive into bone - takes days.

Front 349

Causes of Ketonuria

Back 349

1. Dehydration and decreased PO intake
2. Ethanol abuse
3. Diabetic ketoacidosis

Front 350

Give 5 contraindications to Tenectaplase (TKA).

Back 350

1. Recent Stroke - 3 mo
2. REcent major surgery
3. Active bleeding
4. Hemorrhagic stroke ever!
5. Uncontrolled severe HTN
6. Brain tumor or AVM
8. Suspeted aortic dissection

Front 351

Give 3 side effects of Tenectaplase (TKA).

Back 351

1. Reperfusion arrythmia - don't need to treat
2. Stroke
3. Bleeding - GI

Front 352

How does treatment differ in MI with cardiogenic shock?

Back 352

1. TKA will not be effective due to decreased coronary perfusion.
2. Stabalize the patient
3. Then arrange for prompt angioplasty

Front 353

What are the treatment goals for TKA and PCI and when should you no longer administer?

Back 353

1. 90 minutes from arrival for PCI
2. 30 minutes from arrival for TKA
3. Within 12 hours of symptom onset

Front 354

TKA and PCI
1. Indications for reperfusion(3)
2. Reperfusion not indicated

Back 354

1. INDICATIONS
a. symptoms w/in 12 hours
b. ST >1mm in 2 contiguous leads
c. New LBBB

2. NOT INDICATED
a. Old LBBB
b. ST depression - except in leads II, III, aVF - then do a 15 lead.

Front 355

A pt. comes into the ER comatose, found on the street. You're not sure what the toxidrome is. Name 3 drugs you can give NOW.

Back 355

1. Thiamine
2. Glucose - 1 amp of D50W
3. Naloxone

Front 356

Describe a RAPID NEUROLOGICAL EXAM on a comatose patient. (4).

Back 356

1. Head and Neck - Skin, Skull, Tympanic,C-Spine X-rays, Flex neck for Menigitis. CN - PERL, fundi, corneal and gag reflex.

2. Motor and Sensory - nail bed pressure and sternal rub

3. General - skin, rashes, IV marks, Cardiac, Resp, Abdo exam

4. GCS

Front 357

You have a comatose patient with focal neurological findings - left hemiparesis. You also suspect menigitis. Should you do an LP?

Back 357

NO! Need a head CT with any focal signs in order to rule out increased intracranial pressure and prevent herniation.

Front 358

Give the criteria for a MIGRAINE Headache.

Back 358

TWO of
1. Moderate to severe
2. Pulsating
3.Unilateral
4.Inhibits activity

PLUS ONE of:
1. N + V
2. Phonophobia and Photophobia

PLUS Attacks have occured
1. At least 5 times AND
2. Last 4-72h

Front 359

Give 5 treatments for Migraine Headache in the ER.

Back 359

USE ALL of These Together:
1. Advil - Pain
2. Prochloperazine or metochlopramide - Anti-dopaminergic = N + V
3. Ketorolac - powerful NSAID
4. Sumatriptan - 5HT agonist = vasoconstriction
5. IV Fluids

Front 360

Give 4 treatments for the PREVENTION of MIGRAINES.

Back 360

1. Beta-Blockers
2. SSRIs
3. CCB
4. Valproate

Front 361

What is the most sensitive test for Subarachnoid Hemorrhage?

Back 361

LP - 100% sensitive by 12 hours and Xanthochromia lasts up to 14 days.

CT is 95% sensitive if done within 12 hours of onset.

Front 362

Name 5 features of a Subarachnoid Hemorrhage Headache.

Back 362

1. Sudden onset
2. Worst of life
3. Worst at onset
4. Occured with exertion - sex/exercise
5. Focal deficits common, but later in presentation.

Front 363

GIve 5 features of a headache that is due to INCREASED ICP.

Back 363

1. Worst in morning
2. Worse when supine or bending over
3. Neurological symptoms
4. Changes in mood and behaviour
5. No vomiting or photophobia

Front 364

Give 5 features of a headache due to MENINGITIS.

Back 364

1. Fever
2. Progressive over hours or days
3. Altered LOC
4. Signs of Focal Infection
5. Meningeal signs = + Kernig and Brudzinski

Front 365

Describe Kernig and Brudzinski Signs.

Back 365

Meningitis Signs.

Kernig - Patient is supine. Flex Hip to 90 degrees. Attempt to extend knee to full 180 degrees. Patient will have back pain and resist if positive.

2. Brudzinski - Patient seated in bed, knees flexed to 90 degrees, knees flexed to 90 degrees. Try to bring chin to chest - patient will resist and complain of pain.

Front 366

Temporal Ateritis
1. Clinical Features (5)
2. Dx (2)
3. Tx (1)

Back 366

1. Over 50, temporal headache, tenderness to temporal artery, +/- visual changes and eventually blindness.

2. Elevated ESR >50mm/h, temporal artery biopsy.

3. IV steroids.

Front 367

How should MENINGITIS be treated in the adult patient? (2)

Back 367

1. Start empiric antibiotics before LP results or diagnosis. AMP + CEFT + VANCO or AMP + CEFT + GENT

2. IV Dexamethasone is now a standard of care.

Front 368

GENERIC NAME: cyclobenzaprine
BRAND NAME: Flexeril
1. Class
2. Uses
3. Doses
4. Side effects

Back 368

GENERIC NAME: cyclobenzaprine
BRAND NAME: Flexeril

DRUG CLASS AND MECHANISM: Related to the tricyclic antidepressants with similar side effects. Cyclobenzaprine is a muscle relaxant. Specifically, cyclobenzaprine relieves muscle spasm when the spasm is due to local problems (that is, problems originating in the muscle itself and not in the nerves controlling the muscles). Cyclobenzaprine has no effect on muscle function. Cyclobenzaprine seems to accomplish its beneficial effect through a complex mechanism within the nervous system, probably in the brainstem.

PREPARATIONS: Tablets: 10mg.

STORAGE: Tablets should be stored between 5° and 30° C (41° and 86°F).

PRESCRIBED FOR: Cyclobenzaprine is used together with rest and physical therapy for short-term relief of painful muscle conditions. It is only for short-term use, up to 2 to 3 weeks.

DOSING: Cyclobenzaprine is most often prescribed three times daily but should be taken according to the physician's recommendations.

DRUG INTERACTIONS: Cyclobenzaprine is chemically related to the tricyclic class of antidepressants (e.g. amitriptyline, Elavil; nortriptyline, Pamelor). As such, it should not be taken with or within two weeks of any monoamine oxidase inhibitor, for example, isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and procarbazine (Matulane). High fever, convulsions and even death can occur when these drugs are used together. Additionally, cyclobenzaprine interacts with other medications and drugs that slow the brain's processes, such as alcohol, barbiturates, benzodiazepines (e.g. lorazepam, Ativan), and narcotics.

PREGNANCY: There are no adequate studies of cyclobenzaprine in pregnant women. However, studies in animals suggest no important effects on the fetus. Cyclobenzaprine therefore can be used in pregnancy if the physician feels that it is necessary.

NURSING MOTHERS: It is not known whether cyclobenzaprine is secreted in milk. However, since it is related to the tricyclic antidepressants, some of which are excreted in breast milk, caution is advised in using this medication in lactating women.

SIDE EFFECTS: Among the most common side effects of cyclobenzaprine are drowsiness (which occurs in between 1 in 6 and 1 in 3 persons), dry mouth (between 1 in 14 and 1 in 4), and dizziness (between 1 in 30 and 1 in 9). Other reported side effects, for which the incidence is less than 1 in 30, include nausea, tiredness, constipation, blurred vision, unpleasant taste, nervousness, confusion, and abdominal pain or discomfort.

Front 369

Acute MI - Give 8 Medications and their contraindications.

Back 369

1. ABCs (O2, ECG etc.)
2. ASA Chewed - 15% decreased mortality and biggest bang of all meds for MI.
3. Tenectplase (within 12h) door to needle 30 min or PCI (within 12h) - door to ballon 90 min
4. IV Heparin 1mg/kg, Enoxaparin or Fondaparinox 2.5mg SL all equivalent efficacy.
5. Clopidogrel (300 mg loading for under 75, 75mg for over 75) and then 75mg od indefinitely.
6. Morphine - only for symptoms and not with shock, avoid in right ventricular MI.
7. Beta Blockers - No IV - only PO metoprolol, not in hypotension, copd, asthma, left ventricular failure.
8. Nitrates - 2 puffs or 1 tablet. Not in right ventricular
8. Statins within 24h
9. ACEI - captopril 25mg po

Front 370

Give 2 definitions of acute MI

Back 370

1. ST elevation in 2 contiguous leads greater than 1mm of elevation.

2. New LBBB defined by previous ECG.

Front 371

A 27 year-old man is brought into the ER after a bicycling accident. A car door suddenly opened in front of him, of which he smashed into and was thrown 15 feet. On examination, he is drowsy and confused. He opens his eyes when his name is called. He mumbles words that you understand but the sentences do not make sense. He moves all four limbs but does not respond to any commands. He is able to pull both hands away when pinched and squirms when his sternum is rubbed, making no effort to stop you. What is his Glasgow COMA Scale score?

Back 371

10
E - 3
V - 3
M - 4

Front 372

Which of the following are not consistent with primary (spontaneous) bacterial peritonitis?
a) Abdominal discomfort and fever
b) Ascitic fluid neutrophil count of >250x106 cells/L
c) Ascitic fluid WBC count of >500x106 cells/L
d) Multiple organisms on culture and sensitivity of ascitic fluid

Back 372

d) Multiple organisms on culture and sensitivity of ascitic fluid

Normally no source of infection is found.

Front 373

Describe the features, risk factors and criteria for Spontaneous bacterial peritonitis (SBP).

Back 373

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of ascitic fluid. Generally, no source of the infecting agent is easily identifiable, but contamination of dialysate can cause the condition among those receiving peritoneal dialysis (PD). Spontaneous bacterial peritonitis occurs in both children and adults and is a well-known and ominous complication in patients with cirrhosis.1 Of patients with cirrhosis who have spontaneous bacterial peritonitis, 70% are Child-Pugh class C. In these patients, the development of spontaneous bacterial peritonitis is associated with a poor long-term prognosis. Once thought to occur only in those individuals with alcoholic cirrhosis, spontaneous bacterial peritonitis is now known to affect patients with cirrhosis from any cause.

Children with nephrosis or systemic lupus erythematosus who have ascites have a high risk of developing spontaneous bacterial peritonitis.

Spontaneous bacterial peritonitis can occur as a complication of any disease state that produces the clinical syndrome of ascites, such as congestive heart failure and Budd-Chiari syndrome.

Front 374

A 25 year-old known substance abuser is brought to the ED with a suspected overdose. Which of the following is not considered a universal antidote?
a) Glucose
b) Oxygen
c) Calcium gluconate
d) Naloxone
e) Thiamine

Back 374

c) Calcium gluconate

Front 375

4) Prolonged vomiting is associated with what electrolyte abnormality?
a) Hypochloremic hypokalemic metabolic acidosis
b) Hypochloremic hypokalemic metabolic alkalosis
c) Hyperchloremic metabolic acidosis
d) Hyperkalemia
e) None of the above

Back 375

b) Hypochloremic hypokalemic metabolic alkalosis

Front 376

5) A 37 year-old male arrives at the Emergency Department unconscious. He is warm and sweaty. His heart rate is 52 bpm, his BP is 90/60. His pupils are constricted,
his eyes are teary, and he is drooling. You assume he is suffering from a toxidrome.
What antidote will you give him?
a) Flumazenil
b) Naloxone
c) Glucagon
d) Atropine
e) Ethanol

Back 376

d) Atropine

Front 377

6) A 16 year-old girl is brought to hospital by her frantic parents after a bee sting. Vitals
signs are BP 70/40, RR 30 and laboured, HR 140, T 37.5. Which of the following would not be an option in her management?
a) Epinephrine
b) Diphenhydramine
c) Methylprednisolone
d) Salbutomol
e) Atropine

Back 377

e) Atropine

Front 378

7) Tension pneumothorax is best diagnosed with:
a) Stat CT scan
b) Chest x-ray
c) Watch and wait
d) Clinical exam
e) None of the above

Back 378

d) Clinical exam

Front 379

8) A patient presents with decreased level of consciousness. On exam he has pinpoint
pupils and is unresponsive. Which of the following is NOT a likely etiology?
a) Cerebellar infarct
b) TCA overdose
c) Morphine overdose
d) Pons hemorrhage
e) Ethanol overdose

Back 379

b) TCA overdose

Front 380

9) A 41 y/o male alcoholic is brought into the ED by ambulance. He has been seizing for
approximately 20 minutes. Appropriate actions in the next 5 minutes may include all of the following EXCEPT:
a) Endotracheal intubation, if unable to stop the seizure rapidly
b) Administration of IV anticonvulsants
c) Performing a complete set of vital signs
d) Ordering a stat EEG

Back 380

d) Ordering a stat EEG

Front 381

Calcium Channel Blockers - classify

Back 381

Classify - Dihydropyridine (pines) – amlodipine and nefedipine (Norvasc and Adalat) – relax cardiac and smooth muscle. Non- Dihydropyridine – Diltiazem and Verapamil – same as above and inhibits AV and SA nodes

Front 382

Mechanism of action of Calcium Channel Blockers

Back 382

Dihydropyridine – inhibit Ca++ influx into cardiac and smooth muscle cells, relaxing vessels and the heart . Non- Dihydropyridine - same properties as above, plus inhibits AV node and SA node to lesser extent

Front 383

Uses of Calcium Channel Blockers.

Back 383

Uses - Dihydropyridine (pines) – HTN, Migraine prevention. Non-Dihydropyridine – Angina, PSVT, Atrial Fib/ Flutter

Front 384

Name 3 side effects of calcium channel blockers.

Back 384

Hypotension, leg edema and

Front 385

Describe the symptoms, ecg features and management of PSVT

Back 385

Asymptomatic, usually young male with palpitations. Regular sinus tachycardia 150-180bpm. Vagal manoevres, adenosine 6mg x2 then 12mg.

Front 386

Describe the symptoms, key features and management of Pulmonary Hypertension

Back 386

Management – Sildenafil, Prostacyclin or Bosantin

Front 387

Describe how endothelial cell relaxation and constriction is medicated , how the various treatments work on this system and the connection to Pulmonary Hypertension.

Back 387

2 parallel cycles – endothelin vs. NO, Prostacyclin vs. Thromboxane. Relaxation – mediated by NO and prostacyclin – Sildenafil increases NO concentration, Prostacyclin works against thromboxane to relax endothelial cells. Constriction – Endothelin and Thromboxane

Front 388

How should niacin be taken, most common side effect and how to minimize it?

Back 388

Take at night with some lifh food, most common side effect is flushing, can couterqct it in those that have it by taking ASA 325mg 30 minutes prior to niacin.

Front 389

How should you manage hypertension in heart block syndromes such as a Mobitz Type 2 Wenkeback?

Back 389

NEVER give Non-Dihydropyridin (diltiazem and verapamil)), Beta-Blocker or Digoxin. Consider ACEi, ARB, HCTZ

Front 390

How should niacin be taken, most common side effect and how to minimize it?

Back 390

Take at night with some lifh food, most common side effect is flushing, can couterqct it in those that have it by taking ASA 325mg 30 minutes prior to niacin.

Front 391

What is the role of High-sensitivity C-reactive protein in relation to CAD?

Back 391

High-sensitivity C-reactive protein may be clinically useful in identifying individuals who are at higher risk for CAD than that predicted by a global risk assessment, in particular in patients with abdominal obesity or a calculated 10-year risk between 10% and 20%. A high-sensitivity C-reactive protein level of less than 1.0 mg/L indicates low risk for cardiovascular disease, between 1.0 mg/L to 3.0 mg/L indicates moderate risk and more than 3.0 mg/L indicates high risk. High risk patients should have their LDL aggressively lowered to below 2, ideally 1.5.

Front 392

Give 4 treatment options for an elevated LDL.

Back 392

Atorvastatin/Lipitor 10 mg - 80 mg, Rosuvastatin/Crestor 10 mg - 40 mg, Simvastatin/Zocor 10 mg - 80 mg, Ezetimibe 10 mg, Bezafibrate 400 mg, Fenofibrate 100 mg, Niaspan 0.5 g - 2 g

Front 393

Give 3 side effects of losartan and ARBs. Give a standard dose for CHF and evidence supporting use.

Back 393

Hypotension, hyperkalemia and and renal impairment. HEAAL STUDY Lancet 2009 shows that 150mg od reduces mortality in NYHA 2-4 in those intolerant to ACEi and should be titrate up to this dose unless side effects supersede.

Front 394

Give 4 side effects of ACEi

Back 394

Hypotension, hyperkalemia, renal impairment and cough is most common.