PANRE Emergency Medicine 4 — Questions and Answers
Question 1: A 40-year-old male presents with a high-pressure injection injury to the index finger from a paint gun. The wound looks deceptively small. What is the correct management?
- Clean, dress, and discharge with oral antibiotics
- Emergent hand surgery consultation for surgical debridement (Correct answer)
- Observe for 6 hours and reassess
- Apply a splint and refer to clinic in 48 hours
Correct answer: Emergent hand surgery consultation for surgical debridement
High-pressure injection injuries spread material along fascial planes and carry a high risk of tissue necrosis and amputation; emergent surgical debridement is mandatory.
Question 2: A 55-year-old presents with sudden-onset tearing chest pain radiating to the back. BP is 180/100 in the right arm and 140/80 in the left arm. CT angiography is ordered. What is the most likely diagnosis?
- Pulmonary embolism
- Type A aortic dissection (Correct answer)
- Myocardial infarction
- Boerhaave syndrome
Correct answer: Type A aortic dissection
Tearing chest pain with inter-arm blood pressure differential strongly suggests aortic dissection; Type A involves the ascending aorta and requires emergent surgery.
Question 3: A 19-year-old presents with fever, neck stiffness, and a non-blanching petechial rash spreading rapidly. What pathogen is most likely responsible?
- Streptococcus pneumoniae
- Haemophilus influenzae
- Neisseria meningitidis (Correct answer)
- Listeria monocytogenes
Correct answer: Neisseria meningitidis
Neisseria meningitidis causes meningococcemia, characterized by rapidly spreading petechiae or purpura that do not blanch, indicating a septicemic emergency.
Question 4: A 72-year-old woman on digoxin presents with nausea, yellow-green visual halos, and bradycardia with a heart rate of 40 bpm. Digoxin level is 3.2 ng/mL. What is the specific antidote?
- Calcium gluconate
- Atropine
- Digoxin-specific antibody fragments (Digibind/DigiFab) (Correct answer)
- Sodium bicarbonate
Correct answer: Digoxin-specific antibody fragments (Digibind/DigiFab)
Digoxin toxicity with life-threatening bradycardia is treated with digoxin-specific Fab antibody fragments, which rapidly bind and inactivate free digoxin.
Question 5: A 34-year-old female presents with right-sided pleuritic chest pain, tachycardia, and dyspnea 5 days after knee surgery. D-dimer is elevated. CT-PA confirms pulmonary embolism. She is hemodynamically stable. What is the first-line treatment?
- Systemic thrombolytics (tPA)
- Anticoagulation with unfractionated heparin or LMWH (Correct answer)
- Catheter-directed thrombolysis
- IVC filter placement only
Correct answer: Anticoagulation with unfractionated heparin or LMWH
Hemodynamically stable pulmonary embolism is treated with therapeutic anticoagulation; thrombolytics are reserved for massive PE with hemodynamic compromise.
Question 6: A 6-year-old presents with wheezing, accessory muscle use, and an O2 saturation of 88%. After two doses of nebulized albuterol and one dose of ipratropium, the patient's condition is unchanged. What should be added?
- IV aminophylline
- IV or oral corticosteroids and consider IV magnesium sulfate (Correct answer)
- Heliox alone
- Intubate immediately
Correct answer: IV or oral corticosteroids and consider IV magnesium sulfate
Severe acute asthma unresponsive to bronchodilators requires systemic corticosteroids and IV magnesium sulfate, which acts as a bronchodilator.
Question 7: A 25-year-old presents after ingesting unknown pills with pinpoint pupils, respiratory rate of 6, and a GCS of 6. What is the immediate pharmacologic intervention?
- Flumazenil IV
- Naloxone IV or IM (Correct answer)
- Activated charcoal via NGT
- N-acetylcysteine IV
Correct answer: Naloxone IV or IM
The opioid toxidrome (miosis, respiratory depression, CNS depression) is reversed with naloxone, an opioid receptor antagonist.
PANRE Emergency Medicine 4
A 40-year-old male presents with a high-pressure injection injury to the index finger from a paint gun.
The wound looks deceptively small.
What is the correct management?