CGRN Managing Adverse Events 2 — Questions and Answers
Question 1: A patient develops subcutaneous emphysema in the neck after upper endoscopy. What complication should be suspected?
- Pneumothorax
- Esophageal perforation (Correct answer)
- Allergic reaction to sedation
- Mucosal tear without perforation
Correct answer: Esophageal perforation
Subcutaneous emphysema in the neck after EGD is a classic sign of esophageal perforation.
Esophageal perforation occurs in ~0.03% of diagnostic EGDs. Air escapes through the perforation into the mediastinum and tracks to the neck. Other signs include chest pain and Hamman's sign (mediastinal crunch). Confirm with CT scan.
Question 2: What is the recommended reversal agent for midazolam oversedation during endoscopy?
- Naloxone
- Flumazenil (Correct answer)
- Atropine
- Epinephrine
Correct answer: Flumazenil
Flumazenil is the specific benzodiazepine antagonist for midazolam-induced oversedation.
Flumazenil 0.2 mg IV over 15 seconds, up to 1 mg total. It has a shorter half-life (40-80 min) than midazolam (1.5-2.5 hr), so resedation can occur. Contraindicated in chronic benzodiazepine users (seizure risk).
Question 3: A patient develops severe abdominal pain, rigidity, and free air on X-ray after colonoscopy with polypectomy. What is the diagnosis?
- Post-polypectomy syndrome
- Colonic perforation (Correct answer)
- Acute pancreatitis
- Ileus
Correct answer: Colonic perforation
Free air (pneumoperitoneum) with peritoneal signs after colonoscopy indicates colonic perforation.
Colonic perforation occurs in 0.1-0.3% of diagnostic and 0.3-1% of therapeutic colonoscopies. Unlike post-polypectomy syndrome, perforation shows pneumoperitoneum. Small recognized perforations may be managed with clips; delayed perforations with peritonitis often require surgery.
Question 4: During ERCP, the patient develops severe epigastric pain radiating to the back with elevated lipase. What complication has occurred?
- Cholangitis
- Post-ERCP pancreatitis (Correct answer)
- Duodenal perforation
- Sphincter of Oddi spasm
Correct answer: Post-ERCP pancreatitis
Post-ERCP pancreatitis is the most common significant ERCP complication, occurring in 3-10% of cases.
PEP is defined as new epigastric pain with lipase/amylase ≥3x ULN. Prophylaxis includes rectal indomethacin 100 mg and aggressive IV hydration with LR. Treatment is supportive.
Question 5: A patient desaturates to 85% during moderate sedation. What is the appropriate nursing response?
- Administer reversal agents immediately
- Perform jaw thrust, increase O2, stimulate the patient, and notify the physician (Correct answer)
- Stop the procedure and call a code
- Increase sedation to prevent movement
Correct answer: Perform jaw thrust, increase O2, stimulate the patient, and notify the physician
Stepwise approach: airway positioning, increase O2, stimulate, and alert the endoscopist.
At SpO2 85%: jaw thrust/chin lift, increase O2, verbal/tactile stimulation, notify endoscopist to pause, suction secretions, consider bag-valve-mask if not improving. Reversal agents only if above measures fail.
Question 6: Which electrolyte imbalance is most common after bowel preparation?
- Hyperkalemia
- Hyponatremia (Correct answer)
- Hypercalcemia
- Hypermagnesemia
Correct answer: Hyponatremia
Hyponatremia is the most clinically significant electrolyte disturbance after bowel preparation, especially in elderly patients.
Mechanisms include excessive free water intake (dilutional hyponatremia), GI sodium losses in diarrheal fluid, and inappropriate ADH secretion. High-risk patients should have electrolytes checked before the procedure.
CGRN Managing Adverse Events 2
A patient develops subcutaneous emphysema in the neck after upper endoscopy.
What complication should be suspected?