ABFAS Emergency Response Procedures 2 — Questions and Answers
Question 1: A patient develops sudden severe chest pain and diaphoresis during a foot and ankle procedure under local anesthesia. What is the FIRST priority action?
- Administer sublingual nitroglycerin immediately
- Stop the procedure and activate the emergency response system (Correct answer)
- Obtain a 12-lead ECG before calling for help
- Administer aspirin 325mg orally
Correct answer: Stop the procedure and activate the emergency response system
Stopping the procedure and activating emergency services is the first priority to ensure timely advanced care for a potential myocardial infarction.
Question 2: Which vasopressor is the FIRST-LINE agent for anaphylactic shock in the surgical setting?
- Norepinephrine 0.1 mcg/kg/min IV
- Epinephrine 0.3-0.5 mg IM (1:1,000 solution) (Correct answer)
- Diphenhydramine 50 mg IV
- Methylprednisolone 125 mg IV
Correct answer: Epinephrine 0.3-0.5 mg IM (1:1,000 solution)
Epinephrine 1:1,000 solution given intramuscularly is the first-line treatment for anaphylaxis due to its rapid alpha and beta adrenergic effects.
Question 3: During a foot procedure, a patient on warfarin develops uncontrolled hemorrhage. In addition to direct pressure, which agent most rapidly reverses warfarin anticoagulation?
- Vitamin K 10 mg IV only
- Fresh frozen plasma (FFP) alone
- 4-factor prothrombin complex concentrate (PCC) (Correct answer)
- Protamine sulfate IV
Correct answer: 4-factor prothrombin complex concentrate (PCC)
4-factor PCC provides rapid reversal of warfarin by replacing factors II, VII, IX, and X and has faster onset than FFP.
Question 4: A patient undergoing regional nerve block develops sudden tinnitus, perioral numbness, and confusion. This presentation is most consistent with:
- Hyperventilation syndrome
- Local anesthetic systemic toxicity (LAST) (Correct answer)
- Vasovagal syncope
- Opioid overdose
Correct answer: Local anesthetic systemic toxicity (LAST)
Tinnitus, perioral numbness, and CNS excitation followed by depression are classic early signs of local anesthetic systemic toxicity (LAST).
Question 5: What is the recommended initial treatment for local anesthetic systemic toxicity (LAST) with cardiovascular collapse?
- Sodium bicarbonate 1 mEq/kg IV bolus
- 20% lipid emulsion therapy (Intralipid) (Correct answer)
- Calcium gluconate 1 g IV
- Adenosine 6 mg rapid IV push
Correct answer: 20% lipid emulsion therapy (Intralipid)
20% lipid emulsion (Intralipid) acts as a 'lipid sink,' sequestering the lipid-soluble local anesthetic and is the specific antidote for LAST.
Question 6: A patient with diabetes develops a postoperative wound with rapid spreading erythema, crepitus on palpation, and a foul odor. The MOST urgent next step is:
- Begin broad-spectrum oral antibiotics and observe for 24 hours
- Order MRI to confirm the diagnosis before surgery
- Emergent surgical debridement and IV antibiotics (Correct answer)
- Apply topical antiseptics and wound vacuum therapy
Correct answer: Emergent surgical debridement and IV antibiotics
Crepitus and rapid spreading erythema indicate necrotizing fasciitis, which requires emergent wide surgical debridement as delays dramatically increase mortality.
Question 7: During a foot surgery, a tourniquet has been inflated for 90 minutes. Upon deflation, the patient develops hypotension and bradycardia. This presentation is most likely caused by:
- Pulmonary embolism from the operative limb
- Tourniquet reperfusion syndrome releasing vasodilatory mediators (Correct answer)
- Anesthetic agent overdose from absorbed local
- Air embolism from the surgical field
Correct answer: Tourniquet reperfusion syndrome releasing vasodilatory mediators
Tourniquet reperfusion syndrome occurs when ischemic metabolites, potassium, and vasodilatory substances are released into systemic circulation upon cuff deflation.
ABFAS Emergency Response Procedures 2
A patient develops sudden severe chest pain and diaphoresis during a foot and ankle procedure under local anesthesia.
What is the FIRST priority action?