A 27-year-old man is brought to the emergency department 45 minutes after being involved in a motor vehicle collision. He is agitated. He has pain in his upper right arm, which he is cradling in his left arm. His temperature is 36.7°C (98°F), pulse is 135/min, respirations are 25/min, and blood pressure is 145/90 mm Hg. His breathing is shallow. Pulse oximetry on 100% oxygen via a non-rebreather face mask shows an oxygen saturation of 83%. He is confused and oriented only to person. Examination shows multiple bruises on the right anterior thoracic wall. The pupils are equal and reactive to light. On inspiration, his right chest wall demonstrates paradoxical inward movement while his left chest wall is expanding. There is pain to palpation and crepitus over his right anterior ribs. The remainder of the examination shows no abnormalities. An x-ray of the chest is shown. Two large-bore IVs are placed. After fluid resuscitation and analgesia, which of the following is the most appropriate next step in management?

Intubation with positive pressure ventilation

Surgical fixation of right third to sixth ribs

A 34-year-old woman is recovering in the post-operative unit following a laparoscopic procedure for chronic endometriosis. She had initially presented with complaints of painful menstrual cramps that kept her bedridden most of the day. She also mentioned to her gynecologist that she had been diagnosed with endometriosis 4 years ago, and she could not find a medication or alternative therapeutic measure that helped. Her medical history was significant for surgery she had 6 years ago to remove tumors she had above her kidneys, after which she was prescribed hydrocortisone. An hour after the laparoscopic procedure, she calls the nurse because she is having difficulty breathing. The nurse records her vital signs include: blood pressure 85/55 mm Hg, respirations 20/min, and pulse 115/min. The patient suddenly loses consciousness. Intravenous fluids are started immediately. She gains consciousness, but her blood pressure is unchanged. Which of the following is the most likely cause of the hypotension?

Improper supplementation of steroids

Bleeding profusely through the surgical site

Infection involving the suture line

Loss of fluids during the procedure

A 34-year-old man presents to the emergency department by ambulance after being involved in a fight. On arrival, there is obvious trauma to his face and neck, and his mouth is full of blood. Seconds after suctioning the blood, his mouth rapidly fills up with blood again. As a result, he is unable to speak to you. An attempt at direct laryngoscopy fails as a result of his injuries. His vital signs are pulse 102/min, blood pressure 110/75 mmHg, and O2 saturation 97%. Which of the following is indicated at this time?

Continuous positive airway pressure (CPAP)

A 63-year-old man undergoes workup for nocturnal dyspnea and what he describes as a "choking" sensation while sleeping. He also endorses fatigue and dyspnea on exertion. Physical exam reveals a normal S1, loud P2, and a neck circumference of 17 inches (43 cm) (normal < 14 inches (< 35 cm)). His temperature is 98.8°F (37°C), blood pressure is 128/82 mmHg, pulse is 86/min, and respirations are 19/min. He undergoes spirometry, which is unrevealing, and polysomnography, which shows 16 hypopneic and apneic events per hour. Mean pulmonary arterial pressure is 30 mmHg. Which of the following complications is this patient most at risk for?

Chronic obstructive pulmonary disease

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 67-year-old man presents to the emergency department with abdominal pain that started 1 hour ago. The patient has a past medical history of diabetes and hypertension as well as a 40 pack-year smoking history. His blood pressure is 107/58 mmHg, pulse is 130/min, respirations are 23/min, and oxygen saturation is 98% on room air. An abdominal ultrasound demonstrates focal dilation of the aorta with peri-aortic fluid. Which of the following is the best next step in management?

Serial annual abdominal ultrasounds

Counsel the patient in smoking cessation

Urgent surgery within the next day

A 19-year-old man is brought to the emergency department 35 minutes after being involved in a high-speed motor vehicle collision. On arrival, he is alert, has mild chest pain, and minimal shortness of breath. He has one episode of vomiting in the hospital. His temperature is 37.3°C (99.1°F), pulse is 108/min, respirations are 23/min, and blood pressure is 90/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows multiple abrasions over his trunk and right upper extremity. There are coarse breath sounds over the right lung base. Cardiac examination shows no murmurs, rubs, or gallop. Infusion of 0.9% saline is begun. He subsequently develops increasing shortness of breath. Arterial blood gas analysis on 60% oxygen shows: pH 7.36 pCO2 39 mm Hg pO2 68 mm Hg HCO3- 18 mEq/L O2 saturation 81% An x-ray of the chest shows patchy, irregular infiltrates over the right lung fields. Which of the following is the most likely diagnosis?

Acute respiratory distress syndrome

Anesthesia for emergency surgery for USMLE Step 2 CK: High-Yield Surgery Lessons

🍔 The Full Stomach Rule

Core Principle: Assume ALL emergency surgery patients have a full stomach, regardless of their last meal.
- This creates a high risk for regurgitation and pulmonary aspiration of gastric contents upon loss of airway reflexes during induction.
- Management cornerstone: Rapid Sequence Intubation (RSI).
ASA-E Classification:
- The suffix 'E' is added to the ASA physical status class (e.g., ASA 2E, ASA 3E).
- It signifies an emergency surgery where a delay could lead to significant morbidity or mortality.

⭐ Key risk factors for aspiration: trauma, pregnancy, obesity, diabetes (gastroparesis), opioid use, and significant pain. These conditions delay gastric emptying.

💉 Management - The RSI Rush

📌 The 7 Ps of Rapid Sequence Intubation (RSI)

Preparation: SOAP-ME mnemonic (Suction, O₂, Airway gear, Pharmacy, Monitors, Equipment).
Preoxygenation: 3-5 mins of 100% Fi$O_2$ to create an apneic oxygen reservoir.
Pretreatment: (Optional) Mitigate physiologic responses (e.g., Fentanyl for ↑ICP).
Paralysis with Induction: Near-simultaneous admin of induction agent then paralytic.
Positioning: "Sniffing position" to align airway axes. Cricoid pressure is controversial.
Placement & Proof: Laryngoscopy & tube placement. Gold standard confirmation: persistent waveform capnography.
Post-intubation Management: Secure tube, initiate mechanical ventilation, provide sedation/analgesia.

Agent	Hemodynamics	Onset	Key Contraindications/Notes
Etomidate	Stable (minimal BP ↓)	<1 min	Adrenal suppression (avoid in sepsis)
Ketamine	↑ BP, ↑ HR, ↑ CO	~1 min	Dissociative; ↑ ICP, severe CAD
Propofol	↓ BP (vasodilation)	<1 min	Hypotension, egg/soy allergy, PRIS risk
Succinylcholine	Fasciculations	<1 min	Depolarizing; Hyper-K+, burns >24h, MH
Rocuronium	Stable	1-2 min	Non-depolarizing; reversible w/ Sugammadex

🚑 Complications - Code Blue Scenarios

Aspiration Pneumonitis (Mendelson's):
- Chemical lung injury from gastric acid (pH < 2.5), often leading to ARDS.
- Management: Immediate oropharyngeal suction, secure airway (intubate if needed), provide supplemental O₂ and PEEP.
- ⚠️ Prophylactic antibiotics are not indicated. Bronchoscopy only for large particulate aspiration causing obstruction.
Post-Intubation Hypotension:
- Causes: Induction agents (e.g., propofol) cause vasodilation; PPV ↓ preload, especially in hypovolemia.
- Management: Pre-optimize with IV fluid bolus. Treat with vasopressors (phenylephrine, norepinephrine) and ↓ anesthetic depth.
Difficult Airway Assessment:
- 📌 LEMON: Look, Evaluate 3-3-2 rule, Mallampati score (≥3), Obstruction/Obesity, Neck mobility.

⭐ Post-intubation hypotension is common in septic or hypovolemic patients due to blunted compensatory tachycardia and vasodilation from induction agents. Pre-emptive fluid resuscitation and "push-dose" pressors can mitigate this.

Can't Intubate, Can't Oxygenate (CICO): A failed airway emergency.

⚡ Biggest Takeaways

Assume every emergency patient has a full stomach, posing a high aspiration risk.

Rapid Sequence Intubation (RSI) is the standard technique to secure the airway quickly and minimize aspiration.

Cricoid pressure (Sellick maneuver) is often applied during RSI, though its routine use is debated.

Succinylcholine is a classic RSI paralytic; avoid in hyperkalemia, burns, or crush injuries.

Rocuronium is a common alternative, rapidly reversed by sugammadex.

Prioritize hemodynamic stability; use etomidate or ketamine for induction in unstable patients.

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