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Easy bruising, lymph node enlargement, and splenomegaly are clinical manifestations of:
- Reason:Leukemia is cancer of the
- blood, and is caused by an abnormal proliferation (production by
- multiplication) of leukocytes (white blood cells) in the bone marrow.
- Leukemic cells impair the normal production of red blood cells (RBCs),
- white blood cells (WBCs), and platelets (thrombocytes); this results in
- anemia, leukopenia (low WBC count), and easy bleeding due to
- thrombocytopenia (low platelet count). In leukemia, excessive white
- blood cells accumulate in major organs (ie, spleen, liver, brain, and
- lymph), causing them to become enlarged (ie, splenomegaly [enlarged
- spleen], adenopathy [enlarged lymph nodes], hepatomegaly [enlarged
- liver]). Other signs and symptoms of leukemia include bone pain (due to
- increased pressure in the medullary canal of the bone), fever, fatigue,
- night sweats, and weight loss.
Functions of the hypothalamus include:
A: influencing breathing.
B: regulating appetite.
C: maintaining equilibrium and balance.
D: controlling level of awareness.
- The “hunger” center of the hypothalamus promotes eating. Among many
- other functions, the hypothalamus regulates body temperature, assists in
- the regulatory control of the pituitary gland, and promotes urine
- release from the bladder. The influence of breathing are functions of
- the pons and medulla, which are a part of the brainstem. Maintenance of
- equilibrium and balance are functions of the cerebellum. Control of
- emotions and level of awareness are functions of the cerebrum, which is
- the largest portion of the brain (also referred to as the gray mater).
You are assessing a young female and are
trying to determine if she experienced a seizure or a syncopal episode.
Which of the following findings is MOST consistent with a seizure?
Her heart rate is 120 beats/min.
The episode occurred while she was standing.
The cardiac monitor displays sinus bradycardia.
A bottle of lorazepam is found in her purse.
- It can be difficult to determine whether a patient experienced a seizure or a syncopal episode (fainting). Therefore, it is important to ascertain what happened before and after the episode. Tachycardia is a common finding following a seizure, when the patient is postictal; it is caused by a sympathetic nervous system discharge that occurred during the seizure. Bradycardia often causes syncope secondary to an increase in vagal tone. Seizures occur regardless of the patient’s position, whereas syncope typically occurs while the patient is standing. Most patients with a history of seizures take medications that prevent seizures, such as phenytoin (Dilantin), valproic acid (Depakote), and carbamazepine (Tegretol), among others. Although benzodiazepines (ie, diazepam [Valium], lorazepam [Ativan]) are the most common class of drugs used to terminate seizures, they are more commonly prescribed for anxiety; they are rarely prescribed to prevent seizures.
Which of the following statements regarding hypoglycemia is correct?A:
A patient with prolonged hypoglycemia may require more than one dose of IV dextrose.
Hypoglycemia typically occurs within 4 to 6 hours after inadvertently taking too much insulin.
The skin of a hypoglycemic patient is typically warm and dry secondary to severe dehydration.
Most diabetic patients develop symptoms when their blood glucose level falls below 90 mg/dL.
- 25 g (50 mL) of 50% dextrose (D50) is usually sufficient to restore adequate circulating blood glucose levels and improve the patient’s
- condition. However, if the hypoglycemic event is severe or prolonged, the patient’s response to treatment may be delayed, thus requiring
- additional dosing. It is important to assess the patient’s blood glucose level (BGL) and mental status after administering dextrose; doing so
- will help determine if additional dextrose is needed. Normal serum glucose levels range from 70 to 120 mg/dL. Hypoglycemia following an inadvertent overdose of insulin typically develops within seconds to minutes. The point at which a hypoglycemic patient becomes symptomatic varies. Some patients may develop symptoms when their BGL falls below 70 or 80 mg/dL; others may not develop symptoms until their BGL falls below 40 or 50 mg/dL. Diabetic patients with severe hypoglycemia (insulin shock, hypoglycemic crisis) usually have cool, clammy skin.
- Patients with severe hyperglycemia (diabetic coma, hyperglycemic crisis) typically present with warm, dry skin; this is a manifestation of
- dehydration secondary to the osmotic diuresis associated with hyperglycemia
Prehospital treatment for a patient with a blood glucose reading of 400 mg/dL and polyuria includes:A:
10 units of insulin via the subcutaneous route.
fluid rehydration with an isotonic crystalloid.
25 g of 50% dextrose via the intravenous route.
40 mg of furosemide via the intravenous route.
- Patients with blood glucose levels of 400 mg/dL and polyuria are dangerously close to hyperglycemic ketoacidosis, if not already there. High levels of blood glucose promote an osmotic diuresis, which explainsthe excessive urination (polyuria); this results in significant
- dehydration. Prehospital treatment is aimed at rehydrating the patient with an isotonic crystalloid solution (ie, normal saline). The patient definitely needs insulin; however, it is rarely given in the prehospital setting. Clearly, additional glucose is not indicated for a patient
- with documented hyperglycemia. Furosemide (Lasix), a loop diuretic, is contraindicated in patients with dehydration or hypovolemia.
What portion of the brain regulates a person's level of consciousness?A:
Reticular activating system
- The reticular activating system (RAS), which is located within the brainstem, controls a person’s state of awareness and level of
- consciousness. Coma following severe head injury indicates brainstem involvement and injury to the RAS. The pons and medulla, also located within the brainstem, are the respiratory centers. The cerebrum, the
- largest part of the brain, controls thought processes and memory. The cerebellum, located inferoposterior to the cerebrum, regulates coordination, balance, and equilibrium.
A middle-aged female with a history of
hypertension presents with an acute onset of tearing abdominal pain. She
is conscious and alert, but restless. Her BP is 86/56 mm Hg, pulse rate
is 120 beats/min, and respirations are 28 breaths/min. You should:
administer 5 mg of morphine to relieve her pain.
determine if her femoral pulses are of equal strength.
vigorously palpate her abdomen for a pulsating mass.
increase her blood pressure with IV fluid boluses.
- Your patient may be experiencing acute dissection of the abdominal aorta. A unilateral femoral pulse deficit (one femoral pulse is weaker than the other) may be observed in patients with dissection of the abdominal aorta—especially if the dissection occurs where the common iliac arteries branch. Vigorous palpation is not indicated for anyone with abdominal pain; it only causes further pain and anxiety, and could aggravate the patient’s condition—especially if an aortic dissection is
- present. The goal of IV fluid therapy is to maintain adequate perfusion; this is most reliably assessed by noting the patient’s mental status and quality of peripheral pulses. The blood pressure needed to maintain adequate perfusion varies from person to person. Establish at least one large-bore IV and be prepared to give fluid boluses if needed (ie,
- mental status decreases, BP falls profoundly, peripheral pulses markedlyweaken). Narcotic analgesia (ie, morphine, fentanyl) may be given to patients with severe abdominal pain; however, this patient is hypotensive, so narcotic analgesia is contraindicated.
A 59-year-old woman with a history of
Grave's disease presents with an altered mental status. Her skin is hot
to the touch and her pulse rate is 160 beats/min. These findings are
MOST consistent with:
- Thyrotoxic crisis (thyroid storm, thyrotoxicosis) is a hypermetabolic clinical syndrome caused by critically high levels of the thyroid hormones T3 (triiodothyronine) and T4 (thyroxine). Signs and symptoms include high fever (as high as 105°F to 106°F [40.5°C to 41.1°C]), hypertension, and profound tachycardia. Untreated, it can lead to cardiac arrest. Thyrotoxic crisis may occur in conjunction with Grave's disease, the most severe and common cause of hyperthyroidism, or it may
- occur if a patient takes too much of their prescribed thyroid supplement(ie, levothyroxine). Advanced hypothyroidism (myxedema) is a hypometabolic clinical syndrome caused by a deficiency of T3 and T4; the patient's signs and symptoms are not consistent with myxedema. Addisonian crisis, an acute manifestation of adrenal insufficiency,
- typically occurs after the abrupt cessation of corticosteroid therapy (ie, prednisone, hydrocortisone); this would not explain the patient's hypermetabolic state. Cushing syndrome, caused by excessive cortisol
- production by the adrenal glands, can also cause a hypermetabolic state. However, given the patient's history of Grave's disease, this is less likely.
What is a common finding in both fresh water and salt water drownings?
Severe metabolic alkalosis
Loss of surfactant
- Though the mechanisms are different in salt water drownings as opposed to fresh water drownings, inadequate oxygenation, which leads to hypoxiaand metabolic acidosis, is common to both and is typically the result
- of laryngospasm.
You are called to transport a patient from
an urgent care clinic to the emergency department. When reviewing the
lab results from the clinic, you note that the patient's
thyroid-stimulating hormone (TSH) level is very high. This indicates:
A: Graves disease.
B: Cushing syndrome.
C: an underactive thyroid.
D: elevated T3/T4 levels.
- Thyroid-stimulating hormone (TSH), a hormone produced by the pituitary gland, stimulates the thyroid gland to produce triiodothyronine (T3) and thyroxine (T4). If the thyroid produces too little of these key hormones, TSH levels will increase in an effort to stimulate the thyroid. Thus, an elevated TSH level indicates hypothyroidism. If the thyroid produces excess T3 and T4, as is the case with Graves disease
- (hyperthyroidism), TSH levels would be correspondingly low. Cushing syndrome is not a disease of the thyroid; it is caused by an excess of cortisol production by the adrenal glands or by excessive use of cortisol or similar corticosteroid (glucocorticoid) hormones, such as prednisone, hydrocortisone, or methylprednisolone.
An older woman presents with severe
weakness, hypotension, lower back pain, and vomiting. Her husband tells
you that she has not taken her prednisone in several days because she
has not been feeling well. Which of the following should you suspect?
- Signs and symptoms of acute adrenal insufficiency can manifest suddenly
- in what is called an addisonian crisis. Abrupt cessation of corticosteroid therapy (ie, prednisone, hydrocortisone) is the most
- common cause of an addisonian crisis. It may also be triggered by acute exacerbation of chronic adrenal insufficiency (Addison disease), usually brought on by stress, trauma, surgery, or a severe infection. In either case, cardiovascular collapse occurs due to a lack of the hormone cortisol; therefore, the chief clinical manifestation of an addisonian crisis is shock. Other signs and symptoms may include weakness; lethargy; fever; severe pain in the lower back, legs, or abdomen; and severe vomiting and diarrhea. Cushing syndrome is caused by excessive cortisol production by the adrenal cortex; it may also occur if large
- amounts of corticosteroids are administered. Pheochromocytoma is an adrenal tumor that causes excessive release of epinephrine and
- norepinephrine; patients with this condition present with hypertension and tachycardia. Thyrotoxic crisis (thyroid storm) is a condition caused by critically high thyroid hormone levels, resulting in a hypermetabolic state. Signs and symptoms include severe tachycardia, hypertension, fever, altered mental status, and possibly heart failure.
A 33-year-old female was stung by a
scorpion 45 minutes ago. She is conscious and alert, and presents with
diffuse urticaria and intense itching. She denies chest tightness or
difficulty breathing. Her breath sounds are clear and equal bilaterally.
Her BP is 134/82 mm Hg, pulse is 104 beats/min and strong, respirations
are 16 breaths/min and unlabored, and her SpO2 is 95% on room air. The
MOST appropriate treatment for this patient includes:
an IV of an isotonic crystalloid, 0.1 mg epinephrine 1:10,000 IV, 25 mg diphenhydramine IV.
assisted ventilation, IV of normal saline, 3 to 5 mL of epinephrine 1:10,000 IV.
oxygen at 2 L/min via nasal cannula, 0.3 mg epinephrine 1:1,000 SQ, IV of normal saline.
supplemental oxygen, IV of an isotonic crystalloid, 25 mg diphenhydramine IV.
- Your patient is experiencing an allergic reaction; she is not in anaphylactic shock. Anaphylaxis typically occurs within minutes
- following exposure to an allergen, although its onset can be delayed for as long as an hour. Because she is hemodynamically stable and is not wheezing, the only drug that is indicated for her is 25 to 50 mg of diphenhydramine (Benadryl)—an antihistamine. Give supplemental oxygen asneeded to maintain her SpO2 above 94%. You should establish vascular access in case her condition worsens and she requires further drug therapy. Unless the patient with an allergic reaction is hypotensive or is wheezing, epinephrine is not indicated. Diphendydramine alone is
- often effective in terminating the allergic reaction.
A 30-year-old man complains of difficulty breathing and a fever for the
past 10 days. He is emaciated, is coughing, and has purple blotches on
his trunk. This patient's clinical presentation is MOST consistent with:
- Signs and symptoms of advanced HIV disease (AIDS) include weight loss, which gives the patient an emaciated appearance; persistent fever; night sweats; fatigue; and purple blotches on the skin, which are malignant
- lesions called Kaposi’s sarcoma. The patient may have pneumonia; however, this would be the result of the immunosuppression associated
- with HIV/AIDS. Kaposi's sarcoma are not observed in patients with tuberculosis, pneumonia (without HIV/AIDS), or hepatitis.
Angioedema in a patient with a severe allergic reaction poses an immediate threat to life secondary to:
congestive heart failure.
Angioedema, caused by the release of histamines, is the result of vascular fluid leakage into the subcutaneous layers of the skin. It is prominent in the face and neck area in patients with severe allergic reactions and can pose a significant threat to the airway.
A 16-year-old boy has a severe headache and
vomiting that has progressively worsened over the past 36 hours. Which
of the following questions would be MOST important to ask him?
Do you have any abdominal pain or diarrhea?
Have you experienced a recent head injury?
Is there a history of meningitis in your family?
Do you have a history of hypertension?
- A severe headache and vomiting that progressively worsens could indicate a subdural hemorrhage; therefore, one of the most important questions to ask the patient is if he has experienced any recent head injury, even
- as far back as a week. Subdural hematomas are the result of venous bleeding and can be insidious in their presentation, with symptoms that often appear hours to days after the initial injury. Hypertension is unlikely in a 16-year-old patient, and meningitis is not a hereditary
Which of the following findings is the MOST clinically significant when assessing a patient with a severe headache?
A: BP of 140/88 mm Hg
B: Retroorbital pressure
C: Nausea or vomiting
D: An unsteady gait
- Most headaches are benign; they are usually not a symptom of a serious underlying problem. Migraine headaches, cluster headaches, tension headaches, and sinus headaches—albeit painful and bothersome—are not life-threatening, and are responsible for the majority of headaches thatpatients experience. Nausea and vomiting are common secondary
- complaints in patients experiencing migraine or cluster headaches. Retroorbital pressure—pressure behind the eyes—is very common in
- patients experiencing a sinus headache. Hypertension can cause a severe headache; however, the patient’s blood pressure is typically much higherthan 140/88 mm Hg. Furthermore, hypertension is often due to a
- sympathetic nervous system discharge in response to the pain of the headache itself. In some patients, a severe headache is caused by a serious underlying problem, such as an intracranial lesion (eg, brain tumor), cerebral abscess, or cerebral aneurysm. In these cases, the expanding lesion or hematoma can cause damage to or put pressure on certain parts of the brain, resulting in abnormal neurologic signs. An unsteady or staggering gait is not a common clinical finding in patientswith a benign headache; you should suspect a serious underlying problem if it is observed.
Which of the following findings is MOST suggestive of myxedema?
B: Weight loss
- Advanced hypothyroidism is sometimes called myxedema. Frequently, patients have localized accumulations of mucinous material in the skin,
- which gives the disease its name (the prefix myx- refers to "mucin," and edema means "swelling"). Myxedema manifests as a general slowing of the body's metabolic processes due to a significant reduction or absence of the thyroid hormones T3 (triiodothyronine) and T4 (thyroxine). Since the thyroid gland regulates the metabolic rate and metabolism produces
- heat energy, patients with myxedema are prone to hypothermia. This also explains why patients with hypothyroidism are poorly tolerant of cold temperatures. Other signs and symptoms of myxedema include lethargy,
- depression, bradycardia, and weight gain. In severe cases, coma and death can occur.
Following ingestion of a toxic dose of acetaminophen, right upper quadrant abdominal pain typically begins within:
A: 24 to 72 hours
B: 4 to 14 days
C: 72 to 96 hours
D: 12 to 24 hours
Acetaminophen, the active ingredient in Tylenol, can cause liver failure and death if a toxic dose is ingested. A unique aspect of acetaminophen toxicity is that its signs and symptoms appear in four distinct stages. Stage I (less than 24 hours) symptoms include nausea, vomiting, anorexia, pallor, and malaise. Stage II (24 to 72 hours) symptoms include right upper quadrant (RUQ) abdominal pain and abdominal tenderness to palpation. Stage III (72 to 96 hours) symptoms include metabolic acidosis, renal failure, coagulopathies, and recurring GI symptoms. During Stage IV (4 to 14 days [or longer]), recovery slowly begins or liver failure progresses and the patient dies. The antidote for acetaminophen toxicity is acetylcysteine (Acetadote); ideally, it should be given less than 8 hours following ingestion.
The clinical presentation of thyroid storm MOST closely resembles that of:
B: heroin overdose.
C: amphetamine use.
Thyroid storm is a life-threatening condition that may occur in patients with hyperthyroidism. Hyperthyroidism is a condition in which the thyroid gland produces too much of the thyroid hormones triiodothyronine (T3) and thyroxine (T4). T3 and T4 play a key role in controlling the body’s basal metabolic rate (BMR). When produced in excess, these thyroid hormones produce signs and symptoms of adrenergic hyperactivity (ie, tachycardia, sweating, palpitations, anxiety). In thyroid storm, these clinical signs would be more severe, including profound tachycardia, dysrhythmias, agitation and paranoia, and cardiovascular collapse. Amphetamines also cause adrenergic hyperactivity; of the choices listed, amphetamine use and thyroid storm would produce the most similar clinical signs. Heroin, a narcotic, causes central nervous system depression, resulting in a decreased level of consciousness, hypoventilation, bradycardia, and hypotension. Advanced hypothyroidism, called myxedema, results from a severe deficiency of T3 and T4. In contrast to thyroid storm, myxedema does not present with signs of adrenergic hyperactivity.
A 64-year-old man presents with an acute onset of left-sided weakness, right-sided facial droop, and slurred speech. He is conscious, but confused. You should be MOST suspicious for:
A: left-sided ischemic stroke.
B: right-sided ischemic stroke.
C: right-sided hemorrhagic stroke.
D: left-sided hemorrhagic stroke.
Recalling that the right side of the brain controls the left side of the body and vice versa, this patient's clinical presentation is most consistent with an ischemic stroke to the right cerebral hemisphere. Ischemic strokes, caused by a blocked cerebral artery, typically present with confusion, unilateral weakness (hemiparesis) or paralysis (hemiplegia) on the opposite (contralateral) side of the stroke, a facial droop on the same (ipsilateral) side as the stroke, and dysarthria (slurred or poorly articulated speech). Pupillary abnormalities, if observed, typically occur on the ipsilateral side because of optic nerve crossover in the brain. The patient's clinical presentation is less consistent with a hemorrhagic stroke, which typically presents with a sudden, severe headache; a rapid loss of consciousness; and signs of increased intracranial pressure (ie, hypertension, bradycardia, breathing abnormalities). A hemorrhagic stroke is the result of a ruptured cerebral artery (ie, an aneurysm).
A 52-year-old man has a headache and visual disturbances that have progressively worsened over the past 3 months. These symptoms are MOST consistent with:
A: a cerebral neoplasm.
B: bacterial meningitis.
C: a subdural bleed.
D: an epidural hematoma.
The patient’s symptoms are consistent with a space-occupying intracranial lesion such as a neoplasm (tumor or growth), which typically presents with a headache, visual disturbances, and other symptoms that progressively worsen over a period of several months. In some patients, a new-onset of seizures may be the only presenting sign of a brain tumor. Subdural hemorrhages commonly present with symptoms within 12 to 24 hours following head trauma. An epidural hematoma presents with symptoms immediately following a head injury and causes rapid clinical deterioration. Patients with bacterial meningitis also experience a rapid progression of symptoms.
In addition to CPR, treatment for a patient in cardiac arrest with a core body temperature of 90°F includes:
A: limiting defibrillation to one attempt only if V-Fib is present.
B: avoiding the use of antidysrhythmics such as amiodarone.
C: spacing epinephrine doses at longer than standard intervals.
D: mild hyperventilation to facilitate the production of heat.
- According to current emergency cardiac care (ECC) guidelines, cardiac arrest in a patient with moderate hypothermia (core body temperature [CBT] between 86°F [30°C] and 93°F [34°C]) should be treated with CPR, a single defibrillation every 2 minutes for V-Fib or pulseless V-Tach, and cardiac medication administration as indicated. However, the medications should be spaced at longer than standard intervals. In moderate hypothermia, the patient’s basal metabolic rate (BMR) is slow, thus the onset and duration of action of medications (ie, vasopressors, antidysrhythmics) will be longer. Hyperventilation should be avoided in any patient. Not only does it hyperinflate the lungs and impede venous return to the heart, it facilitates heat loss, not production. If the cardiac arrest patient is severely hypothermic (CBT < 86°F [30°C]), cardiac medications should be withheld, and defibrillation, if indicated, should be attempted one time only.
A 26-year-old woman was bitten on the leg by a rattlesnake while hiking. She is conscious and alert, but is anxious. Her BP is 114/66 mm Hg, her heart rate is 112 beats/min, her respirations are 20 breaths/min, and her oxygen saturation is 97%. Treatment for her should include:
A: oxygen via nasal cannula, elevating the extremity above the level of the heart, and 1 gm of calcium chloride IV push.
B: oxygen via non-rebreathing mask, applying a chemical ice pack to the bite wound, and splinting the affected extremity.
C: oxygen via non-rebreathing mask, elevating the extremity above the level of the heart, and a 20 mL/kg IV fluid bolus.
D: oxygen via nasal cannula, splinting the affected extremity, and an IV line of normal saline set at a keep-vein-open rate.
- Treatment for a pit viper bite includes placing the patient in a comfortable position, administering supplemental oxygen (given her oxygen saturation [97%], a nasal cannula is appropriate for this patient), splinting the affected extremity and keeping it below the level of the heart, and promptly transporting to an appropriate facility. Monitor the patient's cardiac rhythm and establish an IV line. Fluid boluses are not indicated for this patient because her BP is stable; set the IV at a keep-vein-open (KVO) rate. Calcium chloride is not indicated for snakebites. Do NOT apply ice to a snakebite; doing so causes localized vasoconstriction; if envenomation occurred, this could push the venom further into the circulation. Alert the receiving facility early and be prepared to provide cardiopulmonary support (ie, bag-mask ventilation, IV fluid boluses) if the patient's clinical status deteriorates.
What is the pathophysiologic difference between cyanide and carbon monoxide?
A: Carbon monoxide binds with the hemoglobin molecule.
B: Carbon monoxide destroys the red blood cells.
C: Cyanide attaches to the hemoglobin molecule.
D: Cyanide destroys the cells of the immune system.
Carbon monoxide (CO) binds to the hemoglobin molecule and inhibits the oxygen carrying ability of the blood. CO has an affinity for hemoglobin that is 200 to 250 times greater than that of oxygen. Cyanide blocks the uptake of oxygen at the cellular level. Both result in inadequate oxygenation and cellular death if left untreated.
You are assessing a 32-year-old female who complains of chills, muscle aches, and a headache. She tells you that she began feeling bad a few days ago, and has been taking ibuprofen for her headache. Her blood pressure is 130/72 mm Hg, pulse is 118 beats/min and strong, and respirations are 16 breaths/min and unlabored. The patient denies any significant medical problems and is conscious and alert. Further assessment of this patient will MOST likely reveal:
This patient’s clinical presentation is consistent with infection with the influenza virus—she probably has the flu. Chills are generally an indication of fever, and febrile patients are typically tachycardic. In addition to fever and chills, common signs and symptoms of the flu include muscle aches, anorexia, headache, and malaise. These symptoms are often followed by an upper respiratory infection and cough that may last for up to 7 days. Elderly and immunocompromised patients are at greater risk for secondary bacterial infections—for example, pneumonia—in which case localized wheezing may be observed. Because of her mental status and absence of any significant medical problems, hypoglycemia is unlikely, although it would not be unreasonable to assess her blood glucose level. A rash (ie, purpura, petechiae) is common in patients with severe sepsis; although this patient is ill, she is not septic.
A 34-year-old woman overdosed on amitriptyline. She is unresponsive and has slow, shallow breathing. Her BP is 70/40 mm Hg and her heart rate is 140 beats/min. The cardiac monitor reveals sinus tachycardia. Initial treatment for her should include:
A: high-flow oxygen via nonrebreathing mask and 0.4 to 2 mg of naloxone IV push.
B: assisted ventilation with a bag-mask device and 20 mL/kg normal saline boluses.
C: endotracheal intubation and 1 to 2 mEq/kg of sodium bicarbonate IV push.
D: assisted ventilation with a bag-mask device and 0.2 mg of flumazenil IV push.
Slow, shallow breathing will not produce adequate minute volume and should be treated with assisted ventilation. The patient may require endotracheal intubation, but you must restore minute volume first (think basic!). Amitriptyline is a tricyclic antidepressant (TCA); naloxone (Narcan), a narcotic antagonist, will not reverse its effects. Treat the patient's hypotension with sequential normal saline boluses (20 mL/kg); monitor closely for signs of pulmonary edema. Flumazenil (Romazicon), a benzodiazepine antagonist, should not be given to patients with a TCA overdose; it may cause seizures. Provide continuous ECG monitoring and watch for widening of the QRS complex. If QRS widening occurs, consult with medical control regarding the administration of sodium bicarbonate.
Which of the following patients is at greatest risk for suicide?
A: A man who owns multiple guns and knives B: A woman whose depression acutely improves
C: A woman whose mother committed suicide D: A man who has not slept for over 72 hours
Risk factors for suicide include depression, major negative life changes (ie, financial hardship, loss of a loved one, loss of a job), and marital problems, among others. You should be especially alert for the patient whose depression, especially chronic depression, acutely improves. This is a red flag indicator that the patient has developed a plan that he or she is comfortable with, and that he or she feels as though resolution is near.
After being stung by a hornet, a 34-year-old man is unresponsive, has stridorous respirations, a generalized rash, and swelling to the face and neck. His BP is 70/44 mm Hg, his pulse is 140 beats/min and thready, and his respirations are 36 breaths/min and labored. Which of the following represents the MOST appropriate treatment for him?
A: Blind nasal intubation and 3 to 5 mg of epinephrine 1:10,000 IV or IO
B: Bag-mask ventilation and 0.3 to 0.5 mg of epinephrine 1:1,000 SC
C: Needle cricothyrotomy and 0.3 to 0.5 mg of epinephrine 1:1,000 SC
D: Orotracheal intubation and 0.1 mg of epinephrine 1:10,000 IV or IO
The patient’s airway is rapidly swelling, as evidenced by the stridorous respirations. Additionally, his level of consciousness and vital signs are consistent with shock. His airway is in immediate jeopardy and must be secured before it closes completely. You should insert an endotracheal tube (a smaller than normal tube may be needed) via the orotracheal route and assist his ventilations, establish IV or IO access, and administer 0.1 mg (1 mL) of epinephrine 1:10,000; an epinephrine infusion may be needed for refractory anaphylaxis. Epinephrine by the SC route will be much less effective in this patient because he is in shock and peripheral perfusion is likely minimal. If you cannot successfully intubate him via the orotracheal route, you will likely not be able to intubate him via the nasotracheal route. Therefore, if orotracheal intubation is unsuccessful, you should proceed with a cricothyrotomy at once.
Diarrhea, marked bradycardia, miosis, and hypersalivation are MOST consistent with a/an _____________ toxidrome.
The syndrome-like signs and symptoms of a poisonous agent are called a toxidrome. Toxidromes are useful for remembering the assessment and management of different substances that fall under the same clinical umbrella. Cholinergic agents (ie, Diazinon, orthene, sarin, tabun) stimulate the parasympathetic nervous system by deactivating acetylcholinesterase—an enzyme that regulates the degradation of acetylcholine. The signs and symptoms of cholinergic toxicity—that is, the toxidrome—can be remembered with the mnemonic DUMBELS, which stands for defecation, urination, miosis (pupillary constriction), bradycardia and bronchorrhea, emesis, lacrimation, and salivation. Opiate (narcotic) toxicity presents with bradycardia, respiratory depression, hypotension, and pupillary constriction. Sympatholytic (ie, alpha or beta blocker) toxicity presents with bradycardia, hypotension, and hypoglycemia, among other signs. Amphetamine (upper) toxicity presents with restlessness, pupillary dilation, tachycardia, hypertension, tachypnea, and insomnia, among other signs.
Shorly after his dialysis treatment, a 66-year-old man presents with confusion, a headache, and nausea. You should suspect:
A: severe hyperkalemia.
B: acute air embolism.
C: interstitial nephritis.
D: disequilibrium syndrome.
Dialysis rapidly lowers the concentration of urea in the blood, whereas the concentration of solutes in the cerebrospinal fluid (CSF) remains high. Water moves by osmosis from a solution of lower concentration into a solution of higher concentration. Thus, as a consequence of dialysis, water initially shifts from the bloodstream into the CSF, which mildly increases intracranial pressure. If this occurs, the patient may experience disequilibrium syndrome, a condition characterized by nausea, vomiting, headache, and confusion. After a few hours, the fluid will re-equilibrate between the blood and CSF, and the patient's symptoms will resolve on their own. Interstitial nephritis, a cause of intrarenal acute renal failure, is caused by chronic inflammation of the interstitial cells surrounding the nephrons; this condition would not explain the patient's symptoms. Acute air embolism may occur if air enters any of the fittings or connections in the dialysis system; signs and symptoms include acute dyspnea, hypotension, and cyanosis. Hyperkalemia, an increase in serum potassium, would most likely occur if a patient missed a dialysis treatment; signs and symptoms include profound muscle weakness, QRS widening, and peaked T waves.
When assessing a patient who was stung by a bee, which of the following assessment findings is MOST indicative of anaphylactic shock?
A: Diaphoretic skin
B: Known allergy to bees
C: Flushing of the skin
D: A fine, red rash
Allergic reactions can be mild, moderate, or severe. General signs of an allergic reaction include a fine red rash or hives (urticaria), flushed skin, itching or burning of the skin (pruritis), and watery eyes. In a mild or moderate allergic reaction, respiratory and circulatory functions are generally not affected. If the histamine release is overwhelming, however, the patient develops anaphylactic shock, which is characterized by general signs of an allergic reaction plus respiratory and circulatory compromise. Diaphoresis, a sign of shock, is not typically observed in patients with mild or moderate allergic reactions because systemic perfusion is not compromised. A known allergic history is not, in and of itself, an indicator of anaphylactic shock; however, it should raise your concern that an allergic reaction may occur.
Which of the following is the BEST way to minimize the hypoxia that occurs in an apneic patient following submersion in water?
A: Immediate tracheal intubation
B: Frequent oropharyngeal suctioning
C: Rescue breathing while in the water
D: Prophylactic abdominal thrusts
Personnel with specialized training and experience in water rescue should retrieve a patient from the water whenever possible. As soon you as you reach the victim and determine that he or she is not breathing, immediate rescue breathing (mouth-to-mouth or mouth-to-mask) is the best (and quickest) way to minimize tissue hypoxia. Once the patient is removed from the water, continue ventilations with a bag-mask device and consider tracheal intubation. A significant number of drowning victims regurgitate; suction the oropharynx as needed and consider inserting a gastric tube to decompress the stomach. Do NOT perform abdominal thrusts; this may displace water from the stomach into the lungs, increasing the risk of pneumonitis and subsequent lung infection. Abdominal thrusts are only indicated for patients with a solid foreign body airway obstruction.