SPEX Emergency Medicine 3 — Questions and Answers
Question 1: A 30-year-old female presents with sudden severe headache described as 'the worst of my life.' CT head is negative. What is the next step?
- Discharge with analgesics
- MRI brain with contrast
- Lumbar puncture (Correct answer)
- CT angiography immediately
Correct answer: Lumbar puncture
A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture looking for xanthochromia is required when CT is negative and clinical suspicion is high.
Question 2: Which is the preferred vasopressor for septic shock when adequate fluid resuscitation has failed?
- Epinephrine
- Dopamine
- Norepinephrine (Correct answer)
- Vasopressin
Correct answer: Norepinephrine
Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign guidelines due to its alpha-adrenergic properties with less tachycardia risk.
Question 3: A patient is found unresponsive with pinpoint pupils and slow respirations. Which medication should be administered?
- Flumazenil
- Naloxone (Correct answer)
- Physostigmine
- Glucose
Correct answer: Naloxone
Pinpoint pupils with respiratory depression is the classic opioid toxidrome; naloxone is the specific reversal agent.
Question 4: What is the Parkland formula used for in emergency medicine?
- Calculating medication doses in pediatric patients
- Estimating fluid resuscitation in burn patients (Correct answer)
- Determining transfusion requirements in trauma
- Calculating TPA dosing in stroke patients
Correct answer: Estimating fluid resuscitation in burn patients
The Parkland formula (4 mL × weight in kg × % TBSA burned) estimates the lactated Ringer's solution needed in the first 24 hours post-burn.
Question 5: A patient with known epilepsy presents in status epilepticus still seizing after two doses of benzodiazepines. What is the next preferred agent?
- Phenobarbital
- Levetiracetam or fosphenytoin (Correct answer)
- Propofol infusion
- Ketamine
Correct answer: Levetiracetam or fosphenytoin
After benzodiazepine failure, levetiracetam, fosphenytoin, or valproate are second-line agents for established status epilepticus per current guidelines.
Question 6: Which finding on FAST ultrasound in a hemodynamically unstable trauma patient is an indication for immediate operative intervention?
- Pleural effusion
- Free fluid in the hepatorenal space (Morrison's pouch) (Correct answer)
- Pericardial fat pad
- Bladder distension
Correct answer: Free fluid in the hepatorenal space (Morrison's pouch)
Free intraperitoneal fluid in an unstable trauma patient on FAST indicates hemoperitoneum requiring emergent surgical hemorrhage control.
Question 7: A 55-year-old diabetic presents with vomiting and diffuse abdominal pain. Blood glucose is 520 mg/dL, pH is 7.10, and bicarbonate is 10. Urinalysis shows ketones. What is the correct initial management?
- Insulin bolus first, then fluids
- Normal saline resuscitation and insulin infusion (Correct answer)
- Sodium bicarbonate infusion
- Emergent dialysis
Correct answer: Normal saline resuscitation and insulin infusion
DKA management begins with aggressive IV fluid resuscitation with normal saline followed by insulin infusion; insulin bolus before fluid can worsen hypovolemia.
SPEX Emergency Medicine 3
A 30-year-old female presents with sudden severe headache described as 'the worst of my life.' CT head is negative.
What is the next step?