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McGraw-Hill Emergency Medicine Exam Review (Tintinalli's) Test Bank
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McGraw-Hill Emergency Medicine Exam Review (Tintinalli's) Test Bank
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McGraw -Hill Emergency M edicine Exam Review (Tintinalli's) Test Bank The correct answer is C. Rapid injection to minimize the duration of pain Explanation: There are multiple ways to reduce pain of infiltration of a local anesthetic. They include slow (not fast) injection, warming the solution to body temperature, and injecting through the margins of the wound. Bupivacaine can be buffered as described. Buffer ing the anesthetic solution with sodium bicarbonate will decrease the pain of injection. - Which of the following methods is NOT an appropriate way to decrease the pain of infiltration from a local anesthetic? A Buffering the anesthetic solution with sodiu m bicarbonate prior to infiltration B Injecting through the wound margins instead of through intact skin C Rapid injection to minimize the duration of pain D Using 1 mL of sodium bicarbonate 8.4% to buffer 29 mL of bupivacaine 0.25% E Warming the solution to body temperature before injecting Cardiovascular Disorders - The correct answer is D. Acute myocardial infarction (AMI) Explanation: Cardiogenic shock is mostly commonly due to extensive MI with suppressed myocardial contractility. Pump failure is t he underlying factor in most causes of cardiogenic shock (Table 54 -2). Hypoperfusion, with or without hypotension, is the unifying feature of cardiogenic shock, regardless of etiology. During an AMI, several mechanical complications can precipitate cardiog enic shock, including acute myocardial regurgitation due to papillary muscle rupture, ventricular septal defect (VSD), and free -wall rupture. Mechanical complications cause one -fourth of the cardiogenic shock following AMI. Right ventricular infarction can also cause cardiogenic shock due to loss of preload. Cardiac contractility can also be severely depressed due to sepsis, myocarditis, myocardial contusion, and cardiomyopathy. Mechanical obstruction to forward blood flow can also lead to cardiogenic shock , including aortic stenosis, HCM, mitral stenosis, left atrial myxoma, and pericardial tamponade. Regurgitation of LV output due to chordal rupture or aortic insufficiency can cause profound cardiogenic shock. 85% of users answered correctly. - What is the MOST common cause of cardiogenic shock? A Acute aortic insufficiency B Aortic stenosis C Hypertrophic cardiomyopathy D Acute myocardial infarction (AMI) E Pericardial tamponade The correct answer is A. Chronic pain is more common in elderly patients. Explanation: Chronic pain is more common in elderly patients and the most common site of chronic pain is the back. Complete pain relief is an unrealistic goal for chronic pain patients who present to the emergency department. Chronic pain patients who pres ent to the emergency department may be best helped by referral to a pain clinic or specialists; hospital admission is seldom indicated. - Which is TRUE about chronic pain? A Chronic pain is more common in elderly patients. B Less than 25% of patients whose pain lasts 3 months will continue to have chronic pain for several years. C The goal of emergency treatment should be complete relief of pain. D The head is the most common location of chronic pain. E Patients presenting to the emergency department becaus e of chronic pain are best helped by hospital admission. The correct answer is C. Presence suggests an elevated pulmonary capillary wedge pressure Explanation: The presence of third heart sound, or ventricular filling gallop, has a specificity of 99% and highly suggests increased pulmonary capillary wedge pressure and helps rule in CHF. Detection by stethoscope can be challenging and has a sensitivity of only 20%. Use of digital microphone detection during ECG testing improves sensitivity to 40.2%; specif icity is 88.5%. The presence of an S3 is associated with notably worse outcomes, including a doubling of 90 -day mortality. JVD is another excellent physical finding for an elevated pulmonary capillary wedge pressure, with a specificity of 94% and a sensiti vity of 39%. 87% of users answered correctly. - What is the significance of a third heart sound (S3) in the diagnosis of CHF? A Absence suggests increased 90 -day mortality B Absence suggests worse outcome C Presence suggests an elevated pulmonary capillary wedge pressure D Presence suggests improved outcome E Presence rules out CHF The correct answer is D. Minimal sedation Explanation: Moderate sedation patients generally have their eyes closed and respond slowly to vocal commands. Dissociative sedation is a type of moderate sedation where cortical centers do not receive sensory stimuli. Deep sedation is characterized by a profoundly depressed level of consciousness, with a purposeful motor response elicited only after repeated or painful stimuli. Minimal sedation is characterized by anxiolysis but with normal arousal to verbal stimuli. With general anesthesia, the patient is unarousable. - An anxious 50 -year -old female drug user with a 10 -cm thigh abscess fr om skin -popping is given midazolam (Versed) to facilitate incision and drainage. She remains calm but with her eyes open and cooperative and verbal throughout the procedure. What type of sedation is this called? A Deep sedation B Dissociation C General ane sthesia D Minimal sedation E Moderate sedation The correct answer is E. Rescue PCI Explanation: Rescue PCI is indicated in patients in the following groups after thrombolysis: patients who are in cardiogenic shock and younger than 75 years, patients with severe heart failure or pulmonary edema, patients with hemodynamically compromising ventricular arrhythmias, patients with a large area of myocardium at risk, and for whom fibrinolytic therapy has failed. There is no role for repeat thrombolytic administr ation in this type of patient. A balloon pump might help temporarily, but rescue PCI is the procedure of choice. Nitroglycerin is a poor choice as the patient's BP is too low. Dopamine infusion will increase myocardial oxygen demand. 75% of users answered correctly. - A 65 -year -old male presents with 2 hours of chest pain. He has ST elevations across his precordial leads and is diagnosed with an AMI. He is given thrombolytics in the ED. One hour after administration, he is still having chest pain and his BP is 80/60. The next best course of action would be A Dopamine infusion B Nitroglycerin drip C Placement of an aortic balloon pump D Repeat thrombolytic administration E Rescue PCI The correct answer is B. NSAIDs are an appropriate long -term treatment for chronic low back pain in patients at low risk of side effects. Explanation: Administration of steroids for acute sciatica significantly reduces pain scores, but the benefit appears to last only about 24 hours. A systematic meta -analysis of opioids for chronic back pain found no significant long -term benefit. Despite some lack of long -term studies, it is considered reasonable to use NSAIDs in patients with chronic back pain provided that side effects are anticipated when the decision is made to prescribe them. Cyclobenzaprine (Flexeril) appears to have little benefit beyond that of placebo in chronic back pain. Tricyclic antidepressants have been shown to improve mild to moderate chro nic back pain. - Which of the following is the BEST answer regarding medication for back pain and sciatica? A Cyclobenzaprine (Flexeril) is an appropriate long -term medication for chronic back pain. B NSAIDs are an appropriate long -term treatment for chron ic low back pain in patients at low risk of side effects. C Opioids are appropriate long -term agents to use for chronic back pain. D Steroids are an effective and long -lasting treatment for acute sciatica. E Tricyclic antidepressants are NOT appropriate lo ng-term medications for use in chronic back pain. The correct answer is E. Paralysis Explanation: Paralysis and anesthesia are late findings of ischemic injury that portend loss of limb viability. An adequate collateral blood supply may mask signs of isc hemia in a severely diseased artery. Pain can be the sole and earliest symptom of ischemia in a patient with underlying peripheral vascular disease. 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