SAEM QUESTIONS AND ANSWERS

SAEM QUESTIONS AND ANSWERS Management of Large Subungual Hematoma Correct Answer: Drainage (18-Gauge) or Hot Micro-Cauterization Reason to Avoid Suction in Ear Foreign Body Removal Correct Answer: Perforation of Tympanic Membrane Management of Skin Abscess Correct Answer: Linear Incision for Non-Face vs. Needle Drainage for Face Catheter for Bartholin Cyst Correct Answer: Word Grading of Laryngeal Opening Correct Answer: Cormack-Lehane Preferred Induction Agent in Reactive Airway Disease for Dilation Effects Correct Answer: Ketamine Induction Agent Avoided in Sepsis Due To Adrenal Suppression Correct Answer: Etomidate Sudden-Onset Back Pain Worsened by Coughing Soon After Epidural Anesthesia Correct Answer: Epidural Hematoma Presentation of Adhesive Arachnoiditis Correct Answer: Progressive Neuropathy Tom, Dick, and Very Nervous Harry Correct Answer: Anterior to Posterior of Medial Ankle: Tibialis Posterior, Digitorum Longus, Vein, Nerve, Hallucis Longus Absolute Contra-Indication to Crico-Thyrotomy Correct Answer: Age Under 5 Anesthesia for Suturing D.I.P. of Finger in Patient with Underlying Vascular Disease Correct Answer: Lidocaine (2%) Without Epinephrine Around Digital Nerve for Fingers, Toes, Penis, Nose Earliest Sign of Lidocaine Toxicity (Over 5 mg/kg) Correct Answer: Lightheadedness (Also Peri-Oral Numbness, Tinnitus, Visual and Auditory Disturbances, Shivering, Twitching, and Generalized Tonic-Clonic Seizures) (1) Avoid Vertical Mattress Sutures. (2) Avoid Topical Skin Adhesives (Risk of Dehiscence from Sweating). Correct Answer: Palm Glottis Spasm and Chest Wall Rigidity from Sedative (Rapid High Dose of IV Form) Correct Answer: Fentanyl (Effects Not Always Reversed by Naloxone) Management of Long-Lasting L.P. Headache Correct Answer: Autologous Blood Patch Timing of Tetanus Prophylaxis Correct Answer: Within First Few Days (Suture Within First 24 Hours) Normal C.S.F.-to-Blood Glucose Ratio Correct Answer: 0.6 Size of Needle Decompression Needle Correct Answer: 14 Gauge (2nd Intercostal at Midclavicular Line) Large Paronychia and Cellulitis Correct Answer: Removal of Affected Nail Under Digital Block; Start Antibiotics Signs of Acute Appendicitis Correct Answer: 1. Rovsing: Right Lower from Left Lower. 2. Psoas: Extension. 3. Obturator: Rotation. Suggested by Abdominal Pain Preceding Nausea and Vomiting Correct Answer: Surgery (Small Bowel Obstruction) Peak of Gastric Acid Secretion at Rest Correct Answer: 2 A.M. Timing of Presentation of Hypertrophic Pyloric Stenosis (Non-Bilious) vs. Intussusception (Bilious) Correct Answer: 4 Weeks vs. 8 Months Over 95% Sensitive and Specific for Renal Stones Correct Answer: Helical C.T. Intermittent Left Lower Quadrant Pain (Afebrile), Loose Stools (Non-Bloody); Good Follow-Up Correct Answer: Discharge on High-Fiber Diet (Consider Laxatives and Stool Softeners) Abdominal Wall Condition in Anti-Coagulated Patient with Trauma or Coughing Correct Answer: Rectus Sheath Hematoma (1) Age 30. (2) Prior Abdominal Surgery or Pregnancy. (3) Marathons. Correct Answer: Risk Factors for Cecal (Cross-Country) Volvulus Possible Chest X-Ray Finding of Hepatic Abscess Correct Answer: Right-Sided Effusion and Elevated Hemi-Diaphragm Referred Pain from Ureteral Colic Correct Answer: Inguinal (Ovarian Torsion Does Not Cause Sacral Pain) Elderly Patient, Diverticulitis Without Perforation (Without Peritonitis) Correct Answer: I.V. Fluids (Elderly), Antibiotics, and Bowel Rest (Peritonitis Requires Surgery) Proximal vs. Distal Esophageal Perforation Correct Answer: Iatrogenic vs. Spontaneous Rigidity; Elevated Temperatures, Altered Mental Status, Choreo-Athetosis, Autonomic Dysfunction (Diaphoresis, Incontinence, Arrhythmia) Correct Answer: Dantrolene (Or Bromocriptine, Amantadine, Lorazepam) for Neuroleptic Malignant Syndrome Indicated by Temperature Over 105 Correct Answer: Non-Infectious Extra-Pyramidal: Involuntary Periodic Movements of Tongue, Lips, or Mouth Correct Answer: Tardive Dyskinesia Extra-Pyramidal: Torticollis, Fixed Upper Gaze (Oculogyric Crisis), or Arching of Back (Opisthotonus) Correct Answer: Benztropine (2mg Cogentin) or Benadryl (25mg) for Dystonia from Typical Anti-Psychotics Extra-Pyramidal: Restlessness Correct Answer: Beta-Blocker for Akathisia E.C.G. Finding of Haloperidol Toxicity Correct Answer: Long Q.T. Illicit Drug Causing Vertical Nystagmus Correct Answer: Phencyclidine (PCP) Controls Agitation Without Respiratory Depression (Negligible Anticholinergic Side Effects) Correct Answer: Haloperidol (5mg IM q30); B-52 is Benadryl (50 Milligrams), 5 Milligrams of Haloperidol, and 2 Milligrams of Lorazepam Risk of Protracted Struggle in Restraints Correct Answer: Metabolic Acidosis Risk of Flumazenil in Chronic Benzodiazepine User Correct Answer: Withdrawal Seizures Altered Chronic Alcoholic, Non-Gap Metabolic Acidosis Correct Answer: Isopropyl Alcohol Glucose and Magnesium Recommendations for Altered Alcoholic Correct Answer: 1. Thiamine Before Glucose; and, 2. Give Magnesium Regardless of Magnesium Level (Low Stores). Waxing and Waning Global Inability to Relate to Environment and Process Sensory Input (Increased Alertness and Psychomotor Activity) Correct Answer: Delirium Most Common Dementia Correct Answer: Alzheimer More Common Than Vascular Dementia Management of Seizures in Eclampsia Correct Answer: Magnesium; Consider Labetalol or Hydralazine for Diastolic Over 110 After Seizure Stops Relationship Between Alcohol and Seizures Correct Answer: Direct Toxicity vs. Withdrawal vs. Head Injury from Fall Most Common Cause of Delirium in Elderly Correct Answer: Medications Tooth Fracture of Enamel and Dentin, Yellowish Tinge, No Blood Correct Answer: Ellis 2 Dental Fracture Requires Consultation to Prevent Abscess Formation Obvious Nasal Bone Deformity After Blunt Trauma, Bleeding Controlled by Pressure; No Bone Tenderness, Cranial Nerves Intact; Swollen and Bruised Tender Unilateral Septum Correct Answer: Incision and Drainage of Septal Hematoma Followed by Nasal Packing Eye Blunt Trauma; Pain, Double Vision from Upward Gaze Correct Answer: Entrapment of Inferior Rectus from Inferior Orbital Wall Fracture Head Blunt Trauma, Loss of Consciousness, Currently Seizing; Previous Confusion, Vomiting, and Headache Correct Answer: R.S.I. with Paralytic (Before Addressing Intracranial Pressure) Tension Pneumo-Thorax; Hemodynamically Unstable Correct Answer: Needle in 2nd Intercostal Mid-Clavicular (Anterior) or 4th Intercostal Mid-Axillary (Lateral), Before X-Ray (Chest Tube Takes Too Long) Most Sensitive Bedside Test for Finger Nerve Injury Correct Answer: Two-Point Discrimination O'Riain Test Correct Answer: Wrinkling of Digit in Warm Water Indicates Intact Nerve Ottawa Ankle Rules (Any Positive Requires X-Ray) for Pain in Malleolar Zone Correct Answer: 1. Inability to Walk 4 Steps At Time of Injury and Currently. 2. Tenderness Over Posterior Edge of Either Malleolus. 3. Tenderness Over Navicular or Base of 5th Metatarsal. Suspected Globe Rupture (Enophthalmos and Leakage of Vitreous Humor) Correct Answer: Broad-Spectrum Antibiotics (Tetanus If Necessary); Visual Acuity Assessment Before Consultation (Avoid Pressure Tonometry) Trauma; Unilateral Eye Pain with Extra-Ocular Movement, Proptosis, Decreased Visual Acuity Correct Answer: Lateral Canthotomy for Retro-Bulbar Hematoma Blunt Trauma; Unilateral Epistaxis (Maxillary), Subcutaneous Emphysema, or Anesthesia of Ipsilateral Infra-Orbital Region (V2) Correct Answer: Orbital Blowout Fracture (No Proptosis) Anterior Chamber Meniscus Correct Answer: Hyphema (Blood) vs. Hypopion (Pus) Management of Subconjunctival Hemorrhage Correct Answer: Resolves Without Intervention Gravid Female, Pulseless and Apneic for 2 Minutes; Detectable Fetal Heart Tones Correct Answer: Emergency C-Section (More Viable Than Gravid GSW with Undetectable Fetal Heart Tones) Elderly Extension Injury; Decreased Bilateral Grip Strength Correct Answer: Steroids and Cervical M.R.I. for Central Cord Syndrome (Contusion from Buckling of Ligamentum Flavum) Affected by L.X.-L.Y. Herniation Correct Answer: Y (1) Jefferson Fracture of C1 (Image). (2) Hangman Fracture of C2. (3) Flexion Teardrop Fracture. (4) Bilateral Facet Dislocation. Correct Answer: Unstable Fractures Penetrating Trauma to Zone 1 (Sternal Notch to Cricoid Cartilage) Correct Answer: Angiography (4-Vessel CT), Triple Endoscopy, and Observation Management of Hemodynamically-Stable Liver Laceration from Trauma Correct Answer: Conservative Management; No Emergency Laparotomy Trauma Patient with Bloody Foley Correct Answer: C.T. with I.V. and Trans-Urethral Contrast Chest G.S.W., Unconscious and Pulseless, Systolic of 60 Correct Answer: Emergency Thoracotomy (Lower Success Rates for Blunt Trauma) In Breast, Out Axilla; Hemodynamically-Stable and Clear Breath Sounds Bilaterally; I.V. Access Obtained Correct Answer: (1) Bedside Ultrasound. (2) Intubation and Chest Tube. (3) Portable X-Ray; and, (4) Admit to I.C.U. Stab Wound in 10th Intercostal Space, Absent Breath Sounds; Dyspnea But Hemodynamically-Stable Correct Answer: (1) Chest Tube. (2) Portable X-Ray. (3) Abdominal C.T. Decreased Sensation Over Lateral Palm Correct Answer: Median Nerve Injury from Distal Radius Fracture Leg Externally-Rotated (And Abducted) Correct Answer: Femoral Neck Fracture (ER = RE) Leg Internally-Rotated Correct Answer: Posterior Hip Dislocation Popliteal Pain After Impact on Planted Foot; Pale Cold Foot, No Distal Pulses Correct Answer: Sedate and Reduce Without X-Rays Eikenella Correct Answer: Aggressive Mouth Flora Requiring Prophylactic Lactam-Lactamase After Human Bite Definitively Determines Entry and Exit Points Correct Answer: Forensic Specialist (Emergency Department Must Describe Wounds But Never Speculate) Small Pneumo-Thorax on Chest C.T.; Hemodynamically-Stable Correct Answer: 100% Oxygen Flexion and Compression of Vertebral Body, Resulting in Paralysis and Loss of Pain and Temperature Sensation Below Correct Answer: Anterior Cord from Anterior