General EM

Question 1

what is the most common congenital heart abnormality associated with WPW

Answer 1

Ebstein anomaly

Question 2

definition of status epilepticus

Answer 2

seizure lasting longer than 5 minutes OR 2 or more seizures without regaining consciousness between them

Question 3

key historical features when assessing seizure in the ED

Answer 3

presence of a preceding aura, abrupt or gradual onset, progression of motor activity, loss of bowel or bladder control, presence of oral injury, and whether the activity was localized or generalized and symmetric or unilateral, duration of the episode and determine the presence of postictal confusion or lethargy.

Question 4

common precipitating factors for seizures in epilepsy patients

Answer 4

missed doses of antiepileptic medications; recent alterations in medication, including dosage change or conversion from brand name; sleep deprivation; increased strenuous activity; infection; electrolyte disturbances; and alcohol or substance use or withdrawal.

Question 5

first line in status epilepticus

Answer 5

lorazepam 2mg IV

Question 6

second line in status epilepticus

Answer 6

phenytoin loading dose 20mg/kg .. rate of 50mg/min

Question 7

third line, refractory status epilepticus

Answer 7

propofol 1mg/kg IV

Question 8

risk factors for aortic dissection

Answer 8

• chronic hypertension
• Marfan, Ehlers-Danlos, bicuspid aortic valve, famhx of dissection
• chronic cocaine or amphetamine use
• previous cardiac surgery

Question 9

Stanford classification Type A aortic dissection means

Answer 9

any dissection involving ASCENDING aorta

Question 10

Stanford classification Type B aortic dissection

Answer 10

dissection involving only the descending aorta

Question 11

3 historical features most highly associated with aortic dissection

Answer 11

abrupt onset, pain described as ripping or tearing, severe in intensity

Question 12

physical exam findings in aortic dissection

Answer 12

SBP or pulse deficit in extremities, new onset aortic insufficiency murmur, focal neuro deficit PLUS chest, abdo or back pain, and shock or hypotension

Question 13

CXR findings in aortic dissection

Answer 13

widened mediastinum, abnormal aortic contour, displacement of aortic intimal calcification from previous CXR, pleural effusion, or deviation of trachea, bronchus, or esophagus

Question 14

imaging study to diagnose aortic dissection

Answer 14

CT angiogram with contrast

Question 15

goal blood pressure in aortic dissection

Answer 15

below 120mmHg systolic

Question 16

agent of choice for bp lowering in aortic dissection

Answer 16

short-acting β-blockers such as propranolol, labetalol, or esmolol are preferred over long-acting β-blockers.

Question 17

management of type A aortic dissection

Answer 17

surgery, endovascular repair

Question 18

diagnosis of temporal arteritis

Answer 18

need 3 of 5;

1. age > 50
2. new headache
3. temporal artery abnormality (tender, decreased pulsation)
4. ESR > 50
5. abnormal temporal artery biopsy

Question 19

risk factors for subarachnoid hemorrhage

Answer 19

Hypertension
Smoking
Excessive alcohol consumption
Polycystic kidney disease
Family history of subarachnoid hemorrhage
Coarctation of the aorta
Marfan's syndrome
Ehlers-Danlos syndrome type IV
α1-Antitrypsin deficiency

Question 20

BP target in aortic dissection

Answer 20

below 120/80

Question 21

BP target in ischemic stroke

Answer 21

receiving thrombolysis - below 185/110

no thrombolysis- treat if above 220/120 (lower by 15%)

Question 22

BP target in intraparenchymal hemorrhage

Answer 22

SBP below 180 - INTERACT2 trial showed no benefit for below 140

Question 23

risk factors for venous thromboembolism

Answer 23

age > 50
obesity, BMI >35 increases risk
pregnancy/postpartum state
prior VTE (highest recurrence for unprovoked)
solid cancers (adenocarcinomas and metastatic disease highest risk)
hematologic (acute leukemias and myeloma have highest risk)
thrombophilias (non O blood type, Factor V Leiden, lupus AC, protein C/S deficiency, shortened aPTT)
recent surgery (endotracheal intubation or epidural anesthesia within past 4 weeks)
immobility (2 contiguous joints highest risk, ie. long arm cast)
bed rest (becomes risk at 72 hours)
indwelling catheters (ie. PICC)
travel (flights >6 hours)
CHF (related to systolic function)
stroke (greatest in 1st month after)
estrogen (highest in first few months of use)
non-infectious inflammatory conditions (IBD, lupus, nephrotic syndrome)

Question 24

syndrome that occurs in patients with PE who have a PFO

Answer 24

paradoxical embolism syndrome - due to shower of emboli through R–>L shunt due to increased right sided pressure due to PE, causes stroke like symptoms

Question 25

ECG changes associated with PE

Answer 25

``` sinus tachycardia S1Q3invertedTin3 incomplete RBBB complete RBBB T wave inversion in leads V1-4 ```

Question 26

PERC criteria (9) use in low clinical probability <15%

Answer 26

1. age under 50 2. pulse below 100 3. SpO2 greater than 94% 4. no hemoptysis 5. no previous DVT/PE 6. no active cancer 7. no recent surg/immob 8. no estrogen 9. no leg swelling

Question 27

Wells for DVT

Answer 27

- active cancer - paralysis, paresis or immob of lower extremity - bedridden for >3 days because of surg - localized tenderness along deep venous system - swelling >3cm difference between calves - entire leg swollen - unilateral pitting edema - collateral superficial veins - alternative diagnosis as or more likely - prior history of DVT/PE

Question 28

Wells for PE

Answer 28

- suspected DVT - alt diagnosis less likely than PE - active ca. - hemoptysis - pulse > 100 - prior VTE - immob in past 4 weeks

Question 29

potential for false positive D-dimer results in

Answer 29

``` age > 70 pregnancy active cancer or mets surgery in past week liver disease rheumatoid arthritis infections trauma ```

Question 30

potential for false negative D-dimer

Answer 30

``` warfarin therapy symptoms lasting over 5 days presence of small clots isolated pulmonary infarction lipemia isolated calf vein thrombosis ```

Question 31

treatment of PE

Answer 31

anticoagulants - DOACs - apixaban

Question 32

preferred agent for VTE in malignancy

Answer 32

LMWH

Question 33

preferred agent for VTE in renal failure or hemodynamic instability

Answer 33

UFH

Question 34

treatment of DVT causing phlegmasia cerulea dolens

Answer 34

UFH, place limb neutral level, arrange for catheter directed thrombolysis (if cannot occur within 6 hours, consider systemic thrombolytics)

Question 35

treatment of DVT in arm with PICC

Answer 35

remove PICC, anticoagulant as usual

Question 36

treatment of superficial thrombophelbitis

Answer 36

NSAID, voltaren gel; anticoagulate IF extensive

Question 37

treatment of isolated calf vein thrombosis

Answer 37

3 months anticoagulation OR reultrasound in 1 week to assess progression, if none do not treat

Question 38

definition of massive PE

Answer 38

systolic blood pressure of <90 mm Hg for >15 minutes, a systolic blood pressure of <100 mm Hg with a history of hypertension, or a >40% reduction in baseline systolic blood pressure

Question 39

definition of submassive PE

Answer 39

normal BP but evidence of strain

Question 40

less severe PE

Answer 40

normal BP, no strain

Question 41

treatment of massive PE

Answer 41

thrombolysis

Question 42

indication for hospital admission in DVT

Answer 42

- extensive iliofemoral DVT with circulatory compromise - increased risk of bleeding (coagulopathy, PUD, liver disease) - limited CV reserve, need to monitor for hypoxemia - risk of poor compliance - contraindication to LMWH or DOAC, requiring UFH - known or suspected coexistent PE - high suspicion of HITT - renal insufficiency

Question 43

who to treat with sub segmental PE ?

Answer 43

active cancer patients

Question 44

most common cause of wheezing in infants

Answer 44

bronchiolitis

Question 45

3 presentations consistent with unstable angina

Answer 45

1) angina occurring at rest that is prolonged typically >20 mins 2) new onset angina that limits physical activity (ie. walking 1-2 blocks or climbing a flight of stairs) 3) angina that is occurring more frequently, with less activity and lasts longer

Question 46

TIMI score components

Answer 46

Age 65 y or older 3 or more traditional risk factors for coronary artery disease Prior coronary stenosis of 50% or more ST-segment deviation on presenting electrocardiogram 2 or more anginal events in prior 24 h Aspirin use within the 7 d prior to presentation Elevated cardiac markers The presence of each of the above is assigned 1 point. The maximum possible score is 7.

Question 47

if you have a patient with an inferior MI you should get ___

Answer 47

an ECG with right sided VR4 to look for RV infarct

Question 48

Sgarbossa criteria

Answer 48

1. concordant ST deviation >1mm 2. ST-segment depression of 1 mm or more in leads V1, V2, or V3 3. discordant ST deviation >5mm

Question 49

deeply inverted T waves OR variant pattern of biphasic T waves in the V2, V3

Answer 49

Wellen's syndrome - indicative of critical LAD stenosis; often present when pt pain free and resolve when pain ongoing

Question 50

STEMI criteria

Answer 50

1mm of elevation in 2 contiguous leads, in any leads except V2-V3 need 2mm of V2-V3 in men over 40, 1.5mm in women 2.5mm in men under 40

Question 51

treatment of STEMI

Answer 51

aspirin 160mg chew, nitroglycerin spray 0.4mg q5min x 3, plavix 300mg po, unfractionated heparin IV, /fondaparinux SC, metoprolol 50mg po, PCI/fibrinolytics

Question 52

contraindications to fibrinolytics in STEMI

Answer 52

Absolute contraindications Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g., arteriovenous malformation) Known intracranial neoplasm Ischemic stroke within 3 mo Active internal bleeding (excluding menses) Suspected aortic dissection or pericarditis Relative contraindications Severe uncontrolled blood pressure (>180/100 mm Hg) History of chronic, severe, poorly controlled hypertension History of prior ischemic stroke >3 mo or known intracranial pathology not covered in contraindications Current use of anticoagulants with known INR >2–3 Known bleeding diathesis Recent trauma (past 2 wk) Prolonged CPR (>10 min) Major surgery (<3 wk) Noncompressible vascular punctures (including subclavian and internal jugular central lines) Recent internal bleeding (within 2–4 wk) Patients treated previously with streptokinase should not receive streptokinase a second time Pregnancy Active peptic ulcer disease Other medical conditions likely to increase risk of bleeding (e.g., diabetic retinopathy)

Question 53

indications for beta blocker in acute MI

Answer 53

can give within first 24 hours to see benefit if there are no: (1) signs of heart failure, (2) evidence of a low cardiac output state, (3) increased risk for cardiogenic shock (cumulatively: age >70 years old, systolic blood pressure <120 mm Hg, sinus tachycardia >110 beats/min or bradycardia <60 beats/min, and longer duration of STEMI symptoms before diagnosis and treatment), or (4) standard relative contraindications to β-blockade (PR interval >0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease)

Question 54

complications of MI

Answer 54

dysrhythmias heart failure cardiogenic shock ventricular free wall rupture can cause tamponade interventricular septal rupture can cause new murmur papillary muscle rupture (inferior MI) new murmur --> surgical mgmt pericarditis RV infarct

Question 55

indications for temporary transcutaneous pacing in AMI

Answer 55

``` Unresponsive symptomatic bradycardia Mobitz II or higher AV blocks New LBBB and bifascicular blocks RBBB or LBBB with first-degree block Some cases with stable bradycardia and new or indeterminate-age RBBB ```

Question 56

indications for temporary transvenous pacing in AMI

Answer 56

Asystole Unresponsive symptomatic bradycardia Mobitz II or higher AV blocks New or indeterminate-age LBBB Alternating bundle-branch block RBBB or LBBB with first-degree block Consider in RBBB with left anterior or posterior hemiblocks Overdrive pacing in unresponsive ventricular tachycardia Unresponsive recurrent sinus pauses (>3 s)

Question 57

most sensitive finding for placental abruption after trauma in pregnancy

Answer 57

uterine irritability (more than three contractions per hour)

Question 58

how to position pregnant trauma patient

Answer 58

wedge under the right hip area, tilting the patient approximately 30 degrees to the left, to prevent hypotension from inferior vena cava compression by the gravid uterus

Question 59

checklist for trauma in pregnancy

Answer 59

Before arrival: Assemble ED, obstetrics, and trauma team, as appropriate for >20 wk gestation Attend to maternal airway, breathing, and circulation as a priority for both mother and fetus. Increase volume resuscitation 50% above that given to nonpregnant patients. Maintain patient in the semi-left lateral decubitus position, or manually deflect the uterus to the left. Bedside US: FAST for intraperitoneal fluid and to determine fetal heart rate and estimate fetal age to determine viability. Initiate fetal cardiotocographic monitoring as soon as possible and continue for at least 4–6 h even if the patient is apparently uninjured and > 20 weeks gestation. Perform needed imaging. Include blood typing and Rh status in laboratory studies. Administer Rho(D) immunoglobulin to Rh-negative mothers. Give tetanus as indicated. Screen for potential intimate partner violence.

Question 60

high risk features mandating Xray in C spine

Answer 60

age over 65 dangerous mechanism (fall from elevation >3feet/5 stairs, axial load to head (ie. diving), MVC > 100km/h, rollover or ejection, motorized recreational vehicle, bicycle struck or collision) paresthesias in extremities OR no presence of low risk features = imaging

Question 61

any low risk factor in Cspine rules

Answer 61

``` simple rearend (excludes - pushed into oncoming traffic, hit by bus/large truck, rollover, hit by high speed vehicle) sitting position in ED ambulatory at any time delayed onset of pain absence of midline tenderness ```