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. To learn more about PEER VIII, or to order it, go to www.acep.org/bookstore.
- In which of the following patients should urinary catheterization be avoided?
A. 66-year-old man with hemoperitoneum
B. 72-year-old woman with neck of femur fracture
C. 75-year-old man in cardiogenic shock
D. 78-year-old woman with urinary tract infection
- . Which of the following signs or symptoms seen in carbon monoxide poisoning is the most common?
A. Cherry red skin
- An 11-month-old boy presents 3 hours after falling off a 4-foot-high step and landing directly on his head on the sidewalk. He is awake and alert on examination with age-appropriate vital signs. There is a 4-cm boggy hematoma overlying the site of impact. Which bone is most likely to be fractured?
- When performing an emergency department thoracotomy, after the incision has been made and the pleural cavity has been entered, in the presence of cardiac arrest and with no obvious injury on entry, what should be accomplished first?
A. Begin direct cardiac compressions
B. Clamp the aorta
C. Open the pericardium
D. Pass a nasogastric tube to help distinguish the aorta from the esophagus
- The most common form of migraine headache is:
A. Basilar-type migraine
B. Hemiplegic migraine
C. Migraine without aura
D. Ophthalmoplegic migraine
- The answer is D, 78-year-old woman with urinary tract infection.
(Centers for Disease Control and Prevention [catheter-associated UTI], 8-48; Marx, 1301; Tintinalli, 642)
Isolated urinary tract infections take longer to clear, even with appropriate antibiotic use, when a urinary catheter is left in place. Recently, there has been an increased recognition of the effect of urinary catheters in the risk of urinary tract infections, particularly in hospitalized or institutionalized patients. These infections are referred to as catheter-associated urinary tract infections (CA-UTI or CAUTI). There is significant evidence that many patients are catheterized for the convenience of staff and not for any therapeutic benefit. National guidelines have emerged as to which patients potentially benefit from the placement of a urinary catheter (the risk of infection notwithstanding) and in which patients the risks of a CAUTI outweigh the benefits of urinary catheterization. Urinary catheterization continues to be indicated in patients with acute urinary retention, critically ill patients who require measurements of urine output (cardiogenic shock), and in patients with multiple pelvic injuries or proximal femur injuries requiring immobilization (neck of femur fracture and multiple pelvic fractures). If a patient is able to void on his or her own, then the use of in-and-out catheters to collect a urine specimen is associated with an increased rate of infection and should be avoided when possible.
- The answer is D, Headache.
(Marx, 2036-2038; Nelson, 1660-1661; Wolfson, 1464-1466)
Carbon monoxide (CO) poisoning can manifest with a variety of nonspecific signs and symptoms. Of those listed, headache is by far the most common. In developed nations, CO remains the most common cause of acute poison-related deaths. It is formed by incomplete combustion of any carbonaceous fuel, and its danger partly owes to the fact it is invisible, odorless, and nonirritating. The adverse effect of CO is ultimately due to its binding to iron found in hemoglobin, myoglobin, and intracellular cytochrome. It binds to hemoglobin with a much higher affinity (250 times) than does oxygen, and it shifts the oxygen dissociation curve so that at a given partial pressure of oxygen the bound oxygen (oxyhemoglobin) is held tighter. By binding to myoglobin, the normal function of myoglobin to store and transfer oxygen in muscle (such as the heart) is disrupted. Additionally, dissolved CO binds to intracellular cytochromes and leads to inhibition of oxidative phosphorylation similar to cyanide. Hence, CO can prevent both cellular oxygen delivery and intracellular oxygen utilization. The most adversely affected organs are those with high oxygen utilization such as the brain and the heart. Poisoning can manifest with a variety of nonspecific signs and symptoms depending on the length, quantity of exposure, and patient age and underlying disease processes. Symptoms are various, nonspecific, and often attributed to other diseases such as viral illness; they include headache, nausea, vomiting, angina, depressed level of consciousness, hypotension, convulsions, coma, dysrhythmias, and death. Cherry red skin owing to the color of carboxyhemoglobin is an autopsy finding and almost never clinically present. Headache is a very common symptom and far more common than the others listed. Physicians must be aware of the nonspecific presenting symptoms to ensure the correct diagnosis and avoid sending a patient back into a potentially lethal environment.
- The answer is B, Parietal.
(Fleisher, 1428-1430; Marx, 2256)
Skull fractures occur in 2 per 1,000 infants annually and in 0.5 to 1 per 1,000 children and adolescents. In infants, the parietal bone is the most likely to be fractured, constituting up to 70% of all skull fractures. The next most likely areas of injury in infants are the occipital and temporal bones. The least likely to be injured is the frontal bone. The causes of skull fractures in infants include falls, motor vehicle or other blunt traumas, and nonaccidental injury. Abuse must be a consideration, as skull fractures are the second most common injury seen in these cases. In children and adolescents, the causes of skull fractures are likely from motor vehicle trauma or sports-related injury. Infants are at higher risk of fracture than older pediatric patients because of the immaturity of the bony skull, although this risk decreases after the first year of life. Falls from only 4 to 5 feet can cause significant injury: 50% of infants found to have a skull fracture fell from less than this height. A linear skull fracture is the most common manifestation, and plain radiographs of the skull might miss 25% or more of these injuries. Intracranial injury is obviously more likely in infants with a skull fracture, so CT is recommended if a fracture is found. Clinical findings often note overlying swelling, while palpable bony abnormalities are rare in the linear or minimally depressed skull fracture. The child should also be evaluated for clinical findings of head injury, including level of consciousness, vomiting, and seizures. Few infants require any specific treatment with just a simple skull fracture.
- The answer is C, Open the pericardium.
(Marx, 405; Roberts, 317-318)
It is difficult to rule out cardiac tamponade by visual inspection only, and if there is no apparent cardiac activity, incision of the pericardium should be done first. Compressions can be started next if there is still no cardiac activity, and the aorta can be cross-clamped in the presence of persistent hypotension. A nasogastric tube can help differentiate the esophagus from the aorta, but efforts should not be delayed simply to place the tube. The thoracotomy incision should begin just to the right of the sternum and extend to the stretcher or posterior axillary line in the fourth or fifth intercostal space. The procedure should not be delayed for counting rib spaces; in male patients, the incision should be made beneath the nipple line, and in female patients, at the inframammary fold. Next, the intercostal muscles should be cut with scissors just over the top of the rib to expose the thoracic cavity. The rib spreader should be placed and the space opened to allow visualization of the pericardium. Then, the pericardium should be opened, being careful to avoid the phrenic nerve, which will be posterior to the incised area. The right chest may be opened, if needed, to control hemorrhage from that side.
- The answer is C, Migraine without aura.
(Marx, 1356-1359; Wolfson, 749-750)
Migraine without aura, or common migraine, is the most common type of migraine headache and represents about 80% of migraine-type headaches. Migraine with aura, or classic migraine, is less common. The only difference between the two types is the presence of a preceding aura. These auras are typically focal neurologic symptoms and are most commonly visual. They last for 10 to 20 minutes (rarely up to 1 hour) and then fully resolve. They are commonly characterized as a bright rim of light around an area where vision has been lost (scintillating scotomas); a “zigzagged” wall that moves slowly across the field of vision (fortification spectrums); a flash of light or brief spark (photopsias); or simply blurred vision. Patients typically develop headache symptoms after the aura has resolved. Migraine headaches are often described as unilateral, pulsating, and of moderate to severe intensity. Symptoms associated with migraine headaches include nausea, vomiting, photophobia, phonophobia, osmophobia, and lightheadedness. Cognitive impairment is rare and warrants evaluation for other more concerning etiologies of altered mental status and headache. Basilar-type migraines begin with an aura affecting neurologic functions of the brainstem. These patients can have vision disturbance, at times as severe as blindness, dysarthria, vertigo, tinnitus, paresis, and altered level of consciousness. Like other auras, these symptoms should completely resolve within 1 hour. Hemiplegic migraines begin with an aura that causes a hemiplegia, often associated with sensory changes. The motor findings march slowly while affecting additional muscle groups unlike a stroke, in which the motor function is affected at the same time. These symptoms resolve within 1 hour and are followed by a classic headache. Ophthalmoplegic migraines are rare and are characterized by unilateral headache and ocular nerve findings. The most commonly affected cranial nerve is the third nerve; motor deficits and pupillary findings can occur. Patients with focal neurologic findings should be evaluated for acute intracranial pathology.