A 24-year-old man is brought to the emergency department after being involved in a motor vehicle accident as an unrestrained driver. He was initially found unconscious at the scene but, after a few minutes, he regained consciousness. He says he is having difficulty breathing and has right-sided pleuritic chest pain. A primary trauma survey reveals multiple bruises and lacerations on the anterior chest wall. His temperature is 36.8°C (98.2°F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respiratory rate is 28/min. Physical examination reveals a penetrating injury just below the right nipple. Cardiac examination is significant for jugular venous distention. There is also an absence of breath sounds on the right with hyperresonance to percussion. A bedside chest radiograph reveals evidence of a collapsed right lung with depression of the right hemidiaphragm and tracheal deviation to the left. Which of the following is the most appropriate next step in the management of this patient?
Q92
A 72-year-old man is brought to the physician for the evaluation of severe nosebleeds and two episodes of bloody vomit over the past 40 minutes. He reports that he has had recurrent nosebleeds almost daily for the last 3 weeks. The nosebleeds last between 30 and 40 minutes. He appears pale. His temperature is 36.5°C (97.7°F), pulse is 95/min, and blood pressure is 110/70 mm Hg. Examination of the nose with a speculum does not show an anterior bleeding source. The upper body of this patient is elevated and his head is bent forward. Cold packs are applied and the nose is pinched at the nostrils for 5–10 minutes. Topical phenylephrine is administered. Despite all measures, the nosebleed continues. Anterior and posterior nasal packing is placed, but bleeding persists. Which of the following is the most appropriate next step in management?
Q93
A 58-year-old man with type 2 diabetes mellitus comes to the emergency department because of a 2-day history of dysphagia and swelling in the neck and lower jaw. He has had tooth pain on the left side over the past week, which has made it difficult for him to sleep. Four weeks ago, he had a 3-day episode of flu-like symptoms, including sore throat, that resolved without treatment. He has a history of hypertension. Current medications include metformin and lisinopril. He appears distressed. He is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lbs); his BMI is 31.6 kg/m2. His temperature is 38.4°C (101.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Oral cavity examination shows a decayed lower left third molar with drainage of pus. There is submandibular and anterior neck tenderness and swelling. His leukocyte count is 15,600/mm3, platelet count is 300,000/mm3, and fingerstick blood glucose concentration is 250 mg/dL. Which of the following is the most likely diagnosis?
Q94
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?
Q95
A 68-year-old man comes to the physician because of a 6-month history of difficulty swallowing pieces of meat and choking frequently during meal times. He also sometimes regurgitates foul-smelling, undigested food particles. Examination shows a 3 x 3 cm soft cystic, immobile mass in the upper third of the left side of his neck anterior to the left sternocleidomastoid muscle that becomes prominent when he coughs. A barium swallow shows an accumulation of contrast on the lateral aspect of the neck at the C5 level. Which of the following is the most likely underlying cause for this patient's condition?
Q96
A 79-year-old man is admitted to the intensive care unit for hospital acquired pneumonia, a COPD flare, and acute heart failure requiring intubation and mechanical ventilation. On his first night in the intensive care unit, his temperature is 99.7°F (37.6°C), blood pressure is 107/58 mm Hg, and pulse is 150/min which is a sudden change from his previous vitals. Physical exam is notable for jugular venous distension and a rapid heart rate. The ventilator is checked and is functioning normally. Which of the following is the best next step in management for the most likely diagnosis?
Q97
An 18-year-old man presents to a rural emergency department after being stabbed multiple times. The patient's past medical history is notable for obesity, diabetes, chronic upper respiratory infections, a 10 pack-year smoking history, and heart failure. He is protecting his airway and he is oxygenating and ventilating well. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 24/min, and oxygen saturation is 98% on room air. The patient is started on whole blood and the surgeon on call is contacted to take the patient to the operating room. During the secondary survey, the patient complains of shortness of breath. His blood pressure is 54/14 mmHg, pulse is 200/min, respirations are 24/min, and oxygen saturation is 90% on room air. Physical exam is notable for bilateral wheezing on lung exam. The patient goes into cardiac arrest and after 30 minutes, attempts at resuscitation are terminated. Which of the following is associated with this patient's decompensation during resuscitation?
Q98
A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?
Q99
A 59-year-old man comes to the physician for evaluation of progressively worsening back pain that began about 2 months ago. It started as a dull pain that has now developed into a constant throbbing pain that makes falling asleep difficult. Ibuprofen and acetaminophen do not provide relief. The patient has not had any bowel incontinence, limb weakness, or paresthesias. He has metastatic prostate cancer with known metastasis to the sacrum and left ilium, but has had minimal pain related to these sites. He underwent bilateral orchiectomy two years ago, complicated by urinary incontinence. He currently takes no medications. Vital signs are within normal limits. There is midline tenderness to palpation over the lower lumbar spine. MRI scan of the spine shows a new sclerotic lesion at the L5 vertebral body. Which of the following is the most appropriate next step in management?
Q100
A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 91: A 24-year-old man is brought to the emergency department after being involved in a motor vehicle accident as an unrestrained driver. He was initially found unconscious at the scene but, after a few minutes, he regained consciousness. He says he is having difficulty breathing and has right-sided pleuritic chest pain. A primary trauma survey reveals multiple bruises and lacerations on the anterior chest wall. His temperature is 36.8°C (98.2°F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respiratory rate is 28/min. Physical examination reveals a penetrating injury just below the right nipple. Cardiac examination is significant for jugular venous distention. There is also an absence of breath sounds on the right with hyperresonance to percussion. A bedside chest radiograph reveals evidence of a collapsed right lung with depression of the right hemidiaphragm and tracheal deviation to the left. Which of the following is the most appropriate next step in the management of this patient?
A. Tube thoracostomy at the 2nd intercostal space, midclavicular line
B. Tube thoracostomy at the 5th intercostal space, midclavicular line
C. Tube thoracostomy at the 5th intercostal space, anterior axillary line
D. Needle thoracostomy at the 5th intercostal space, midclavicular line
E. Needle thoracostomy at the 2nd intercostal space, midclavicular line (Correct Answer)
Explanation: **Needle thoracostomy at the 2nd intercostal space, midclavicular line**
- The patient presents with classic signs of **tension pneumothorax**, including respiratory distress, hypotension, tachycardia, jugular venous distention, absent breath sounds, hyperresonance to percussion, tracheal deviation away from the affected side, and mediastinal shift.
- **Needle thoracostomy** in the 2nd intercostal space at the midclavicular line is the most appropriate *initial* life-saving intervention for tension pneumothorax, as it rapidly decompresses the pleural space.
*Tube thoracostomy at the 2nd intercostal space, midclavicular line*
- While a **tube thoracostomy (chest tube insertion)** is the definitive treatment for pneumothorax, it is not the immediate first step for a **tension pneumothorax** due to the time constraint and the need for immediate decompression.
- The 2nd intercostal space, midclavicular line, is an appropriate site for needle decompression, but a chest tube is typically inserted at a different location (5th intercostal space, anterior axillary line).
*Tube thoracostomy at the 5th intercostal space, midclavicular line*
- This location is not the standard site for either needle decompression or definitive chest tube insertion. The **midaxillary or anterior axillary line** is preferred for chest tube placement to avoid neurovascular bundles.
- Again, while a chest tube is needed, it is not the *immediate* first step for a **tension pneumothorax**.
*Tube thoracostomy at the 5th intercostal space, anterior axillary line*
- This is the **correct anatomical location** for definitive chest tube insertion for a pneumothorax or hemothorax.
- However, in the setting of acute **tension pneumothorax**, **needle decompression** is required first to rapidly decompress the intrathoracic pressure and stabilize the patient before a chest tube can be placed.
*Needle thoracostomy at the 5th intercostal space, midclavicular line*
- The **5th intercostal space** is too low for an effective needle decompression of a tension pneumothorax.
- The standard site for needle decompression of a tension pneumothorax is the **2nd intercostal space, midclavicular line**, due to its safety and effectiveness in accessing the pleural space.
Question 92: A 72-year-old man is brought to the physician for the evaluation of severe nosebleeds and two episodes of bloody vomit over the past 40 minutes. He reports that he has had recurrent nosebleeds almost daily for the last 3 weeks. The nosebleeds last between 30 and 40 minutes. He appears pale. His temperature is 36.5°C (97.7°F), pulse is 95/min, and blood pressure is 110/70 mm Hg. Examination of the nose with a speculum does not show an anterior bleeding source. The upper body of this patient is elevated and his head is bent forward. Cold packs are applied and the nose is pinched at the nostrils for 5–10 minutes. Topical phenylephrine is administered. Despite all measures, the nosebleed continues. Anterior and posterior nasal packing is placed, but bleeding persists. Which of the following is the most appropriate next step in management?
A. Endoscopic ligation of the anterior ethmoidal artery
B. Endoscopic ligation of the greater palatine artery
C. Endoscopic ligation of the sphenopalatine artery (Correct Answer)
D. Endoscopic ligation of the posterior ethmoidal artery
E. Endoscopic ligation of the lesser palatine artery
Explanation: ***Endoscopic ligation of the sphenopalatine artery***
- The patient presents with **severe, recurrent epistaxis** that is unresponsive to conservative measures, anterior and posterior packing, indicating a **posterior nasal bleed**. The sphenopalatine artery is the primary blood supply to the posterior nasal cavity.
- **Ligation of the sphenopalatine artery** is a highly effective surgical intervention for intractable posterior epistaxis, providing definitive control of bleeding in such cases.
*Endoscopic ligation of the anterior ethmoidal artery*
- The **anterior ethmoidal artery** primarily supplies the superior and anterior nasal septum and lateral nasal wall; ligation would be considered for **anterior superior epistaxis** that is difficult to control.
- Given the failed extensive packing and the severity of bleeding without an obvious anterior source, the bleeding is likely posterior and more widespread than the anterior ethmoidal artery territory.
*Endoscopic ligation of the greater palatine artery*
- The **greater palatine artery** primarily supplies the hard palate; it is not a major source of epistaxis and its ligation would not address the severe, persistent posterior nasal bleeding.
- This artery's contribution to nasal bleeding is minimal, and it is not typically involved in **recurrent severe epistaxis** that requires surgical intervention.
*Endoscopic ligation of the posterior ethmoidal artery*
- The **posterior ethmoidal artery** supplies a small area of the superior posterior nasal septum and lateral wall. While it can contribute to posterior epistaxis, it is a less common source and less significant than the sphenopalatine artery.
- Ligation of the posterior ethmoidal artery alone would be insufficient if the bleeding is primarily from the **sphenopalatine artery territory**, which supplies a much larger area of the posterior nasal cavity.
*Endoscopic ligation of the lesser palatine artery*
- The **lesser palatine artery** supplies the soft palate and tonsillar area; it is not a significant source of epistaxis and its ligation would not be relevant to controlling severe nasal bleeding.
- This artery plays no substantial role in the blood supply of the nasal cavity and would not be targeted for the treatment of **epistaxis**.
Question 93: A 58-year-old man with type 2 diabetes mellitus comes to the emergency department because of a 2-day history of dysphagia and swelling in the neck and lower jaw. He has had tooth pain on the left side over the past week, which has made it difficult for him to sleep. Four weeks ago, he had a 3-day episode of flu-like symptoms, including sore throat, that resolved without treatment. He has a history of hypertension. Current medications include metformin and lisinopril. He appears distressed. He is 180 cm (5 ft 11 in) tall and weighs 100 kg (220 lbs); his BMI is 31.6 kg/m2. His temperature is 38.4°C (101.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Oral cavity examination shows a decayed lower left third molar with drainage of pus. There is submandibular and anterior neck tenderness and swelling. His leukocyte count is 15,600/mm3, platelet count is 300,000/mm3, and fingerstick blood glucose concentration is 250 mg/dL. Which of the following is the most likely diagnosis?
A. Angioedema
B. Peritonsillar abscess
C. Lymphadenitis
D. Sublingual hematoma
E. Ludwig angina (Correct Answer)
Explanation: ***Ludwig angina***
- This patient presents with **rapidly progressive submandibular and anterior neck swelling**, dysphagia, fever, and a history of a recent dental infection (decayed molar with pus drainage). These are classic signs of **Ludwig angina**, a severe cellulitis of the floor of the mouth.
- The patient's **poorly controlled diabetes** and **obesity** are risk factors for severe infections, and the elevated leukocyte count further supports an active bacterial infection.
*Angioedema*
- **Angioedema** typically presents with rapid swelling of the face, lips, tongue, or larynx, but it is usually **non-pitting** and **painless**, without systemic signs of infection (fever, pus, elevated leukocytes).
- While lisinopril can cause angioedema, the presence of **fever, pus drainage from a tooth, and tenderness** makes an infectious etiology more likely than an allergic or bradykinin-mediated angioedema.
*Peritonsillar abscess*
- A **peritonsillar abscess** is characterized by severe **sore throat**, **trismus**, **"hot potato" voice**, and a **uvular deviation**, which are not reported in this patient.
- While it can cause dysphagia and fever, the primary swelling in this case is submandibular and anterior neck, not peritonsillar.
*Lymphadenitis*
- **Cervical lymphadenitis** involves painful, enlarged **lymph nodes**, often in response to an infection. While the patient has an infection, lymphadenitis would present as discrete node enlargement rather than diffuse, board-like swelling of the floor of the mouth and submandibular space.
- The extensive swelling, dysphagia, and involvement of fascial planes are more consistent with a spreading cellulitis like Ludwig angina.
*Sublingual hematoma*
- A **sublingual hematoma** would typically result from **trauma** or a **coagulopathy**, neither of which is indicated in this patient's history.
- It would also not explain the fever, pus drainage, and elevated leukocyte count indicative of an active infection.
Question 94: 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?
A. Pneumothorax
B. Pulmonary contusion (Correct Answer)
C. Aspiration pneumonia
D. Acute respiratory distress syndrome
E. Pulmonary embolism
Explanation: ***Pulmonary contusion***
- The patient's presentation with **hypoxia**, increasing shortness of breath after a high-speed motor vehicle collision, and **patchy, irregular infiltrates** on chest x-ray despite initial hydration, are highly suggestive of **pulmonary contusion**.
- The coarse breath sounds over the right lung base further support the presence of parenchymal injury and hemorrhage in the lung tissue.
*Pneumothorax*
- While a pneumothorax is common after trauma, the chest x-ray would typically show a **collapsed lung** and **absence of lung markings** in the affected area, which is not described.
- The presence of coarse breath sounds suggests air entry, not a complete absence due to collapsed lung.
*Aspiration pneumonia*
- Although the patient had one episode of vomiting, **aspiration pneumonia** typically develops hours to days after aspiration, presenting with fever and signs of infection.
- The acute onset of symptoms within minutes of trauma and the lack of fever make aspiration pneumonia less likely as the primary diagnosis immediately following the accident.
*Acute respiratory distress syndrome*
- **Acute respiratory distress syndrome (ARDS)** is a severe inflammatory lung injury that typically develops **24 to 72 hours** after an initial insult, not immediately.
- While the patient has hypoxia, the diffuse bilateral infiltrates characteristic of ARDS are not seen, and his symptoms are too acute for ARDS to be the primary cause at 35 minutes post-injury.
*Pulmonary embolism*
- A **pulmonary embolism** would typically present with sudden onset of shortness of breath and pleuritic chest pain, often without significant findings on chest x-ray or presenting with a **wedge-shaped infiltrate**.
- Given the direct chest trauma and immediate onset of respiratory compromise, a pulmonary contusion is a more direct and acute consequence.
Question 95: A 68-year-old man comes to the physician because of a 6-month history of difficulty swallowing pieces of meat and choking frequently during meal times. He also sometimes regurgitates foul-smelling, undigested food particles. Examination shows a 3 x 3 cm soft cystic, immobile mass in the upper third of the left side of his neck anterior to the left sternocleidomastoid muscle that becomes prominent when he coughs. A barium swallow shows an accumulation of contrast on the lateral aspect of the neck at the C5 level. Which of the following is the most likely underlying cause for this patient's condition?
A. Remnant of the embryological omphalomesenteric duct
B. Inadequate relaxation of lower esophageal sphincter
C. Remnant of the thyroglossal duct
D. Increased intrapharyngeal pressure (Correct Answer)
E. Remnant of the second branchial cleft
Explanation: ***Increased intrapharyngeal pressure***
- The symptoms of **dysphagia**, **regurgitation of undigested food**, and a **neck mass prominent with coughing** are classic for a **Zenker's diverticulum**, which results from increased intrapharyngeal pressure causing herniation of mucosa through Killian's triangle.
- The barium swallow showing **contrast accumulation** and the location of the mass further support this diagnosis, as Zenker's diverticula are pseudo-diverticula caused by pulsion from high pressure during swallowing.
*Remnant of the embryological omphalomesenteric duct*
- An **omphalomesenteric duct remnant** typically presents as a **Meckel's diverticulum** in the small intestine or an umbilical fistula, not as a neck mass with swallowing difficulties.
- This embryological anomaly is related to the midgut development and has no connection to pharyngeal issues.
*Inadequate relaxation of lower esophageal sphincter*
- **Inadequate relaxation of the lower esophageal sphincter** (LES) is characteristic of **achalasia**, which causes dysphagia and regurgitation, but typically of *fermented* rather than *undigested* food, and does not present with a palpable neck mass as described.
- Achalasia involves the distal esophagus and does not lead to a pharyngeal outpouching.
*Remnant of the thyroglossal duct*
- A **thyroglossal duct cyst** is a midline neck mass that moves with swallowing and tongue protrusion, which is not consistent with the lateral, pulsion-type mass that becomes prominent with coughing.
- While it can be found in the upper third of the neck, its embryological origin and presentation differ significantly from a Zenker's diverticulum.
*Remnant of the second branchial cleft*
- A **second branchial cleft cyst** is typically a lateral neck mass, often located anterior to the sternocleidomastoid muscle, but it is congenital and does not typically present with progressive dysphagia and regurgitation of undigested food in adulthood, nor does it typically become prominent with coughing due to increased intrapharyngeal pressure.
- These cysts are usually asymptomatic unless infected and are not directly related to swallowing mechanics.
Question 96: A 79-year-old man is admitted to the intensive care unit for hospital acquired pneumonia, a COPD flare, and acute heart failure requiring intubation and mechanical ventilation. On his first night in the intensive care unit, his temperature is 99.7°F (37.6°C), blood pressure is 107/58 mm Hg, and pulse is 150/min which is a sudden change from his previous vitals. Physical exam is notable for jugular venous distension and a rapid heart rate. The ventilator is checked and is functioning normally. Which of the following is the best next step in management for the most likely diagnosis?
A. Tube thoracostomy
B. FAST exam
C. Needle thoracostomy (Correct Answer)
D. Chest radiograph
E. Thoracotomy
Explanation: ***Needle thoracostomy***
- The patient's sudden deterioration with **tachycardia**, **hypotension**, and **jugular venous distension** (JVD) in the setting of positive pressure ventilation strongly suggests a **tension pneumothorax**.
- **Needle decompression** is the immediate life-saving intervention for suspected tension pneumothorax, as delaying treatment for diagnostic imaging could be fatal.
*Tube thoracostomy*
- While a **tube thoracostomy** (chest tube insertion) is the definitive treatment for pneumothorax, it requires more time and resources than needle decompression.
- In a true emergency with signs of tension, needle decompression should be performed first to stabilize the patient, followed by a chest tube.
*FAST exam*
- A **Focused Assessment with Sonography for Trauma (FAST) exam** is primarily used to detect free fluid (usually blood) in the abdomen or pericardium in trauma patients.
- While it can sometimes identify pneumothorax, it is not the fastest or most direct intervention for a suspected tension pneumothorax causing hemodynamic instability.
*Chest radiograph*
- A **chest radiograph (CXR)** is the standard diagnostic tool for pneumothorax, but obtaining and interpreting it would delay urgent intervention in a hemodynamically unstable patient with suspected tension pneumothorax.
- The diagnosis of tension pneumothorax is primarily clinical; treatment should not wait for imaging.
*Thoracotomy*
- A **thoracotomy** is a major surgical procedure involving opening the chest, typically reserved for severe trauma, massive hemorrhage, or complex thoracic issues.
- It is an overly aggressive and inappropriate initial intervention for a suspected tension pneumothorax.
Question 97: An 18-year-old man presents to a rural emergency department after being stabbed multiple times. The patient's past medical history is notable for obesity, diabetes, chronic upper respiratory infections, a 10 pack-year smoking history, and heart failure. He is protecting his airway and he is oxygenating and ventilating well. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 24/min, and oxygen saturation is 98% on room air. The patient is started on whole blood and the surgeon on call is contacted to take the patient to the operating room. During the secondary survey, the patient complains of shortness of breath. His blood pressure is 54/14 mmHg, pulse is 200/min, respirations are 24/min, and oxygen saturation is 90% on room air. Physical exam is notable for bilateral wheezing on lung exam. The patient goes into cardiac arrest and after 30 minutes, attempts at resuscitation are terminated. Which of the following is associated with this patient's decompensation during resuscitation?
A. COPD
B. Congenital long QT syndrome
C. Heart failure
D. IgA deficiency
E. Persistent intraabdominal bleeding (Correct Answer)
Explanation: ***Persistent intraabdominal bleeding***
- The patient's initial presentation with **uncontrolled hemorrhage due to multiple stab wounds** is the most likely cause of his subsequent decompensation and cardiac arrest. Despite transfusion, persistent bleeding would lead to ongoing **hypovolemic shock**, explaining the worsening hypotension and tachycardia.
- The patient's complaint of shortness of breath and wheezing could be a **reaction to hypovolemic shock** or a **transient pulmonary response** related to the ongoing volume loss and metabolic state, rather than a primary respiratory obstructive process.
*COPD*
- While the patient has a smoking history, his age (18 years old) makes significant **COPD** unlikely to be established enough to cause such a rapid and severe decompensation.
- The **wheezing** could be a non-specific response to shock or hypoperfusion, not necessarily indicative of COPD exacerbation in this acute setting.
*Congenital long QT syndrome*
- This condition is a **cardiac electrical disorder** predisposing to arrhythmias, but it is not directly linked to the traumatic injury or the progressive hypovolemic shock in this clinical scenario.
- There is no specific information in the vignette to suggest an **arrhythmia originating from a prolonged QT interval** as the primary cause of his cardiac arrest.
*Heart failure*
- Although the patient has a history of heart failure, his primary and overwhelming problem is **acute hemorrhagic shock** from the stab wounds. The dramatic drop in blood pressure and rise in heart rate point to volume loss, not primarily cardiogenic shock exacerbation.
- While heart failure can complicate resuscitation, it is not the **direct cause of decompensation** in the face of active, life-threatening hemorrhage.
*IgA deficiency*
- **IgA deficiency** is an immunodeficiency associated with recurrent infections, but it has no direct pathophysiological link to acute traumatic hemorrhage or the rapid cardiovascular collapse experienced by this patient.
- It would not explain the sudden severe signs of **hypovolemic shock** or cardiac arrest in this context.
Question 98: A 35-year-old male is brought into the emergency department for a trauma emergency. The emergency medical services states that the patient was wounded with a knife on his upper left thigh near the inguinal ligament. Upon examination in the trauma bay, the patient is awake and alert. His physical exam and FAST exam is normal other than the knife wound. Large bore intravenous lines are inserted into the patient for access and fluids are being administered. Pressure on the knife wound is being held by one of the physicians with adequate control of the bleeding, but the physician notices the blood was previously extravasating in a pulsatile manner. His vitals are BP 100/50, HR 110, T 97.8, RR 22. What is the next best step for this patient?
A. CT lower extremities
B. Radiograph lower extremities
C. Coagulation studies and blood typing/crossmatch
D. Tourniquet of proximal lower extremity
E. Emergent surgery (Correct Answer)
Explanation: ***Emergent surgery***
- The pulsatile bleeding from a thigh wound near the inguinal ligament is highly suggestive of a major arterial injury, such as to the **femoral artery**.
- Given the potential for rapid blood loss and hemodynamic instability, **emergent surgical exploration and repair** are necessary to control the bleeding and prevent further compromise.
*CT lower extremities*
- While CT angiography could further delineate vascular injury, the presence of **active pulsatile bleeding** necessitates immediate surgical intervention rather than delaying for imaging.
- Delaying surgery for imaging risks **exsanguination** and worsening patient outcomes, especially with a blood pressure of **100/50 mmHg** and a heart rate of **110 bpm**, indicating early shock.
*Radiograph lower extremities*
- A radiograph would primarily visualize bone structures and foreign bodies but would not provide adequate information regarding the **vascular injury** and active bleeding.
- It would not change the urgent need for **surgical exploration** to address the pulsatile hemorrhage.
*Coagulation studies and blood typing/crossmatch*
- These are important preparatory steps for major surgery involving significant blood loss, but they should be carried out **concurrently with preparations for emergent surgery**, not instead of it.
- Delaying surgery to await these results would be inappropriate when facing **active arterial bleeding**.
*Tourniquet of proximal lower extremity*
- While a tourniquet can be used for temporary hemorrhage control, especially in an uncontrolled external hemorrhage, the current bleeding is being controlled by **direct pressure**.
- Applying a tourniquet could cause **ischemic damage** to the extremity if applied for too long, and for a deep stab wound, direct compression is often effective until surgical control can be achieved.
Question 99: A 59-year-old man comes to the physician for evaluation of progressively worsening back pain that began about 2 months ago. It started as a dull pain that has now developed into a constant throbbing pain that makes falling asleep difficult. Ibuprofen and acetaminophen do not provide relief. The patient has not had any bowel incontinence, limb weakness, or paresthesias. He has metastatic prostate cancer with known metastasis to the sacrum and left ilium, but has had minimal pain related to these sites. He underwent bilateral orchiectomy two years ago, complicated by urinary incontinence. He currently takes no medications. Vital signs are within normal limits. There is midline tenderness to palpation over the lower lumbar spine. MRI scan of the spine shows a new sclerotic lesion at the L5 vertebral body. Which of the following is the most appropriate next step in management?
A. Prostatectomy
B. Flutamide
C. Spinal surgery
D. Local radiation (Correct Answer)
E. Denosumab
Explanation: ***Local radiation***
- The patient has a new **sclerotic lesion at L5** causing severe, unremitting pain, which is characteristic of **metastatic prostate cancer** to the bone.
- **Local radiation therapy** is highly effective for localized bone pain due to metastases, providing significant pain relief and preventing further bone destruction.
*Prostatectomy*
- **Prostatectomy** is a treatment for localized prostate cancer and would not address existing **metastatic bone disease** causing spinal pain.
- The patient has already undergone bilateral orchiectomy, which achieves **androgen deprivation**, making prostatectomy for pain management inappropriate.
*Flutamide*
- **Flutamide** is an **anti-androgen** used in hormone-sensitive prostate cancer, but the patient has already had an orchiectomy, indicating he is likely on maximum androgen deprivation.
- In cases of progression after initial androgen deprivation, **second-line hormonal therapies** or chemotherapy would be considered, but **local radiation** is more targeted for immediate pain relief from a specific bone lesion.
*Spinal surgery*
- **Spinal surgery** is typically reserved for cases of **spinal cord compression**, neurological deficits (e.g., limb weakness, incontinence), or spinal instability.
- Since the patient has no signs of **spinal cord compression** or neurological deficits, surgical intervention is not the most appropriate initial step for pain management from a bone lesion.
*Denosumab*
- **Denosumab** is a **RANK ligand inhibitor** used to prevent skeletal-related events (SREs) and manage bone pain in metastatic cancer.
- While it helps in overall bone health and pain over time, **local radiation** offers more rapid and direct pain relief for a specific, painful metastatic lesion.
Question 100: A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?
A. Removal of nasal packing (Correct Answer)
B. Urine toxicology screen and empiric naloxone
C. Nafcillin
D. Vancomycin
E. Norepinephrine
Explanation: ***Removal of nasal packing***
- This patient presents with classic **toxic shock syndrome (TSS)** caused by nasal packing following her nasal fracture repair 2 days ago.
- Key diagnostic features include: **purpuric rash** (diffuse macular erythroderma with petechiae), hypotension (90/48 mmHg), tachycardia (150/min), fever, and altered mental status.
- TSS is caused by **Staphylococcus aureus** toxin production, with nasal packing being a well-known risk factor.
- **Immediate removal of the nasal packing** (the source of infection) is the critical first step, followed by fluid resuscitation and empiric anti-staphylococcal antibiotics.
*Urine toxicology screen and empiric naloxone*
- While the patient is an IV drug user, opioid overdose does **not** explain the **purpuric rash**, which is the key diagnostic finding.
- Opioid overdose typically presents with **respiratory depression** (low respiratory rate), not tachypnea (24/min) with normal oxygen saturation.
- The clinical picture is dominated by TSS, not drug toxicity.
*Nafcillin*
- While **nafcillin** (anti-staphylococcal antibiotic) will be needed for TSS treatment, the **first step** is removal of the source (nasal packing).
- Source control takes precedence over antibiotics in foreign body-associated infections.
*Vancomycin*
- Similar to nafcillin, **vancomycin** is appropriate for empiric TSS coverage (especially for MRSA), but must come **after** removal of nasal packing.
- Antibiotics without source control will not adequately treat TSS.
*Norepinephrine*
- While the patient is hypotensive and may eventually require vasopressor support, the **immediate priority** is removing the infectious source.
- TSS-induced shock should be managed with aggressive fluid resuscitation first, and vasopressors are added if fluid resuscitation fails.
