Provided by PEER VIII. PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from the latest edition of PEER VIII. For a complete reference and answer explanations for the questions below, visit emra.org under the Resources tab. To learn more about PEER VIII, or to order it, go to www.acep.org/bookstore.
- Which of the following clinical features is more likely to be seen in an elderly patient with dehydration than in a pediatric patient?
A. Dry mucous membranes
B. Postural hypotension
C. Reduced skin turgor
D. Sunken eyes
- A 60-year-old man with a history of cirrhosis presents with abdominal pain and tense ascites. Paracentesis is performed, and the ascitic fluid granulocyte count is 275 cells/mm3. What is the appropriate next step?
A. Discharge with a prescription for pain medications
B. Obtain surgery consultation
C. Start ceftriaxone
D. Wait for culture results
- A 21-year-old man presents with lacerations over the second and third metacarpophalangeal joints of his right hand after being involved in a fistfight the previous evening. Which of the following statements regarding his treatment is correct?
A. Absorbable sutures should be used because he might not get follow up care
B. Antibiotics are not indicated because the likelihood of infection is low
C. Delayed primary closure or healing by secondary intention is appropriate
D. First-generation cephalosporins should be used as first-line treatment
- Which of the following dysrhythmias is associated with commotio cordis?
B. Atrial fibrillation
C. Pulseless electrical activity
D. Ventricular fibrillation
- A 50-year-old woman presents complaining of a funny feeling in the back of her throat when she swallows; she thinks she has fish bone stuck in her throat. She has no respiratory distress or stridor, and her voice is normal. What is the next step in management?
A. Barium swallow
C. Discharge home
D. Plain radiographs
- The answer is B, Postural hypotension.
(Marx, 2191-2199, 2348-2352; Tintinalli, 402, 971-972)
Postural hypotension is commonly seen in elderly patients with relatively minor volume loss. Frank hypotension can be seen at lower levels of volume loss in elderly patients compared to younger patients; elderly patients are unable to increase their heart rates sufficiently to compensate for volume loss and have loss of autonomic reflexes through physiologic changes of aging, disease processes, and medications. In pediatric patients with dehydration, tachycardia typically predominates until the volume loss is extreme, so hypotension in a pediatric patient implies major volume loss. Postural hypotension is not commonly seen in pediatric patients, most likely because they have very brisk autonomic reflexes and very responsive cardiovascular systems. The clinical signs of extreme dehydration are well characterized in the pediatric population. Many of these clinical signs are shared across age groups and include reduced skin turgor, dry mucus membranes, sunken eyes, and tachycardia. The assessment of fluid status in elderly patients is often more difficult than in pediatric patients, and good evidence is lacking as to what specific clinical signs help guide management. In the elderly, dehydration is also commonly associated with confusion, which is unusual in younger adults and pediatric patients. Skin turgor can be poor in elderly patients at baseline, and it has been suggested that assessing skin turgor over the sternum might be helpful in older patients.
- The answer is C, Start ceftriaxone.
(Marx, 1162; Thomsen, e21; Tintinalli, 569-572)
Patients presenting with signs of spontaneous bacterial peritonitis (SBP) require intravenous ceftriaxone for empiric antibiotic coverage. Spontaneous bacterial peritonitis is an idiopathic bacterial infection of ascitic fluid. It usually occurs in cirrhotic patients with ascites. Portal hypertension created by a cirrhotic liver creates bowel edema and facilitates transmural migration of enteric flora into the immunocompromised peritoneal cavity. The majority of the flora consists of gram-negative Enterobacteriaceae (Escherichia coli, Salmonella, Klebsiella; 63%) and Streptococcus pneumonia (15%). Patients can present with a variety of signs and symptoms but typically present with abdominal pain. Up to 50%, however, are afebrile. Diagnostic workup includes a paracentesis and ascitic fluid analysis with cell count and culture. A polymorphonuclear (PMN) count greater than 250 per cubic millimeter of ascitic fluid correlates with a high incidence of SBP. Definitive diagnosis is achieved by a positive ascitic fluid culture. Patients with SBP require early parenteral antibiotics covering gram-negative organisms. Third-generation cephalosporins such as ceftriaxone are the antibiotics of choice for SBP. Withholding or delaying treatment for culture results increases the risk of worsened disease and death. These patients require medical management with intravenous antibiotics. There is no urgent indication for surgical intervention.
- The answer is C, Delayed primary closure or healing by secondary intention is appropriate.
(Marx, 739-741; Wolfson, 155, 1650)
Clenched-fist injuries should be presumed to be human bite wounds until proved otherwise. For this reason, these wounds should be treated by delayed primary closure or secondary intention if at all possible to avoid the increased risk of infection with closure. If the wound is gaping, it can be loosely approximated to allow for drainage of secretions. Patients with tendon or joint involvement should be admitted and treated with intravenous antibiotics, and a hand surgeon should be consulted. If the wound is closed, nonabsorbable monofilament sutures should be used. Braided sutures provide an additional nidus for infection, as do absorbable sutures. There is a high incidence of infection in these wounds, so antibiotic prophylaxis is recommended. Amoxicillin-clavulanic acid is the current drug of choice. It covers Streptococcus, Staphylococcus (methicillin sensitive), Pasteurella, Bacteroides, and Eikenella, which can commonly infect bite wounds. Eikenella is commonly found in human bite wounds, and Pasteurella is more commonly found in cat bite wounds. Pasteurella is not commonly found in human bite wounds. First-generation cephalosporins might be used to cover skin flora but they do not provide adequate monotherapy for all typical pathogens in human bite wounds.
- The answer is D, Ventricular fibrillation.
(Maron, 917-927; Tintinalli, 1759)
Commotio cordis is ventricular fibrillation that occurs after a blunt blow to the chest in a patient who does not have any structural heart disease. Most victims of commotio cordis are previously healthy athletes who sustain the injury during a sporting event. It is thought that the location of the blow must be directly over the heart, as there is no evidence in humans or experimental models that a blow outside the precordium can cause sudden death. The timing of this blow must occur during the upstroke of the T wave to cause ventricular fibrillation. Commotio cordis leads to sudden cardiac death; because interventions to address ventricular fibrillation are frequently delayed, resuscitation is rare. Appropriate treatment consists of standard CPR according to basic life support/advanced cardiovascular life support guidelines, including defibrillation. Asystole, atrial fibrillation, and pulseless electrical activity are not pathophysiologic rhythms associated with commotio cordis.
- The answer is D, Plain radiographs.
(Marx, 720-724, 1137-1138; Tintinalli, 552-554)
Radiographs are indicated in every patient with a history suggestive of foreign body ingestion. The sensitivity varies with the type of foreign body and location. Radiographs are primarily helpful to identify radiopaque objects, and indirect signs such as soft tissue swelling can be seen. In this case, a fish bone might be seen on a radiograph. If radiographs are nondiagnostic, further workup is required, as inconclusive plain radiographs do not eliminate the possibility of a foreign body. Options for visualization include direct laryngoscopy, indirect laryngoscopy with a mirror, or use of a fiberoptic nasopharyngeal scope. Removal can be accomplished using these techniques as well. Computed tomography of the neck has also been used to identify foreign bodies not seen on plain radiographs. Contrast swallow studies can be helpful if the foreign body is in the esophagus but have limited utility in upper airway foreign bodies. Barium is contraindicated in cases in which esophageal perforation is suspected. Water-soluble iodinated contrast material (brand names Gastrografin, MD-Gastroview) may be used if a study is needed. Patients may be discharged home only after a thorough evaluation. Many of these foreign bodies end up being swallowed but irritate the pharyngeal mucosa, leading to a foreign body sensation.