PANRE Emergency Medicine 5 — Questions and Answers
Question 1: A 58-year-old male with known COPD presents with increasing dyspnea, pursed-lip breathing, and SpO2 of 82% on room air. His PCO2 is 68 mmHg. What is the preferred initial ventilatory support?
- High-flow oxygen via non-rebreather mask
- Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
- Immediate endotracheal intubation
- Nasal cannula at 2 L/min only
Correct answer: Non-invasive positive pressure ventilation (BiPAP)
BiPAP reduces the work of breathing in COPD exacerbation and has been shown to decrease intubation rates and mortality compared to standard oxygen therapy.
Question 2: A 45-year-old construction worker presents with a nail embedded in the plantar surface of his foot through his boot. He is not up to date on tetanus. What is appropriate tetanus management?
- Tetanus toxoid only
- Tetanus immune globulin (TIG) only
- Both tetanus toxoid and tetanus immune globulin (TIG) (Correct answer)
- No tetanus prophylaxis needed if last dose was within 10 years
Correct answer: Both tetanus toxoid and tetanus immune globulin (TIG)
A contaminated, deep puncture wound in an unvaccinated or incompletely vaccinated patient requires both tetanus toxoid and TIG for passive and active immunization.
Question 3: A 33-year-old female at 32 weeks gestation presents with severe headache, BP 168/110, and 3+ proteinuria. She then develops a generalized tonic-clonic seizure. What drug is given to prevent further seizures?
- IV lorazepam
- IV phenytoin
- IV magnesium sulfate (Correct answer)
- IV labetalol
Correct answer: IV magnesium sulfate
Eclampsia (seizures in a preeclamptic patient) is treated and prevented with IV magnesium sulfate, which is superior to other anticonvulsants in this setting.
Question 4: A 17-year-old presents after a motor vehicle collision with distended neck veins, tracheal deviation to the right, absent breath sounds on the left, and hypotension. What is the immediate intervention?
- Chest X-ray before intervention
- Needle thoracostomy on the left at the second intercostal space, midclavicular line (Correct answer)
- Emergency pericardiocentesis
- Intubate and ventilate
Correct answer: Needle thoracostomy on the left at the second intercostal space, midclavicular line
Tension pneumothorax presents with tracheal deviation away from the affected side, absent breath sounds, distended neck veins, and shock — immediate needle decompression is lifesaving.
Question 5: A 62-year-old presents to the ED with confusion, fever of 38.8°C, and jaundice. She reports right upper quadrant pain for 3 days. BP is 90/60. What is the diagnosis?
- Acute hepatitis A
- Ascending cholangitis (Reynold's pentad) (Correct answer)
- Peptic ulcer perforation
- Hepatic abscess
Correct answer: Ascending cholangitis (Reynold's pentad)
Charcot's triad (fever, jaundice, RUQ pain) with added hypotension and confusion constitutes Reynold's pentad, diagnostic of severe ascending cholangitis requiring urgent biliary decompression.
Question 6: A 28-year-old male presents with a displaced mid-shaft femur fracture after a high-speed MVA. He is tachycardic and his Hgb dropped from 14 to 9 g/dL over 2 hours. How much blood can be lost from a closed femur fracture?
- Up to 250 mL
- Up to 500 mL
- Up to 1,000–1,500 mL (Correct answer)
- Greater than 2,000 mL
Correct answer: Up to 1,000–1,500 mL
A closed femur fracture can result in 1,000–1,500 mL of occult blood loss into the thigh compartment, contributing significantly to hemorrhagic shock.
Question 7: A 50-year-old presents with a paraphimosis that has been present for 4 hours. The glans is edematous and the patient is in significant pain. What is the appropriate ED management?
- Emergent urology consult and OR
- Manual reduction after applying ice and sugar compresses to reduce edema (Correct answer)
- Catheter insertion to decompress the bladder first
- Prescribe analgesia and discharge
Correct answer: Manual reduction after applying ice and sugar compresses to reduce edema
Paraphimosis should be managed acutely by reducing penile edema (ice or osmotic agents like sugar) followed by manual reduction of the foreskin; dorsal slit is reserved for failed reduction.
PANRE Emergency Medicine 5
A 58-year-old male with known COPD presents with increasing dyspnea, pursed-lip breathing, and SpO2 of 82% on room air.
His PCO2 is 68 mmHg.
What is the preferred initial ventilatory support?