A 59-year-old man strikes the steering wheel of his car during a low speed automobile accident. In the emergency department he is alert and his vital signs are normal. He complains of mild tenderness on sternal compression. Chest x-ray film shows a widened mediastinum.
The most appropriate first step is to order:
Correct Answer A: A classic history such as this should always trigger a rule out diagnosis for aortic arch dissection. Traumatic dissection is very common in trauma situations and the classical description is a widened mediastinum on plain chest films. However, this finding is highly non-specific and therefore, CT imaging with contrast of the thorax is now the preferred method for ruling out this diagnosis.
Bronchoscopy is used to assess the trachea and upper airways via direct visualization. It has no role in the evaluation of possible aortic injury. Thoracocentesis is used to evaluate fluid present in the pleural space, a so called pleural effusion. A needle is inserted lateral or inferior to the lung but within the pleural space to withdraw fluid for analysis.
Thoracic ultrasonography could refer to imaging of the thorax or of the heart. Regardless, trans-thoracic ultrasound has limited ability to evaluate the aortic arch. A trans-esophageal ultrasound however is exquisitely sensitive for detecting aortic arch injury and allows complete inspection of the aortic root and valve, as well as the coronary cusps and sinuses.
A 35 year old woman is seen in the emergency department because of the sudden onset of severe low back pain 12 hours earlier. The pain began when she bent over to pick up her 2 year old child. Low doses of ibuprofen have eased the discomfort slightly. Careful physical examination, including a neurologic examination, is normal except for evidence of muscle spasm. She believes she has a herniated disc because 2 years ago her father developed the sudden onset of back pain that required immediate surgery.
Which of the following is the most appropriate first step?
Correct Answer D: This patient has an acute back syndrome that is most likely due to lumbosacral muscle sprain or strain. The normal neurologic examination does not suggest any evidence of a radiculopathy, and therefore a disc herniation is less likely. The great majority of these injuries improve with NSAID use and bedrest for approximately three days. Longer periods of bedrest, immobilization, or traction have not been demonstrated to improve outcomes when compared to three days of bedrest.
A 19-year-old woman is admitted unconscious to the Emergency Department following a car accident. She has facial lacerations and a displaced tibial fracture.
Which one of the following is the first priority in management?
Correct Answer D: The initial evaluation follows a protocol of primary survey, resuscitation, secondary survey, and either definitive treatment or transfer to an appropriate trauma center for definitive care. This approach is the heart of the ATLS system, which is designed to identify life-threatening injuries and to initiate stabilizing treatment in a rapidly efficient manner.
The steps of the primary survey are encapsulated by the mnemonic ABC-CAB:
A 25 year old man comes to the emergency department because of pain, swelling and erythema over the metacarpophalangeal joint of the right long finger. Three days ago he struck an opponent in the mouth during an altercation. On physical examination there is an abrasion over the dorsal surface of the joint, pain on passive motion of the finger, and exquisite tenderness along the volar aspect of the finger and metacarpal. His temperature is 38.5°C (101.3°F). X-ray films are normal.
Which of the following is the most appropriate management?
Correct Answer E: The history and physical findings suggest an infective arthritis of the metacarpophalangeal joint. This is most commonly from a puncture or cut on the dorsum of the hand; it is often seen when a fighter’s fist strikes the tooth of his opponent, resulting not only in crushed tissue, but also in inoculation of organisms in the metacarpophalangeal joint, particularly into the metacarpal head. Wounds of human bites should be débrided and irrigated, not sutured, and aggressive intravenous antibiotic therapy is immediately started. All of the other choices, including splinting and exercise, are usually indicated in fracture and dislocation of phalangeal and metacarpal bones. Splinting, antibiotics and reevaluation and splinting and antibiotic therapy are incorrect because he requires debridement.
Which of the following is the least likely to occur post-tonsillectomy?
Correct Answer E: Complications associated with tonsillectomy (with or without adenoidectomy) include adverse effects related to anesthesia, bleeding, infection (choice D), and dehydration (choice B). Pain is an expected outcome and, therefore, is not considered a complication per se. The most common of these potentially serious complications are airway problems, such as laryngospasm and/or bronchospasm (choice C). Postoperative hemorrhage (choice A) following tonsillectomy can be classified as either primary/early (within 24 hours of surgery) or secondary/delayed (greater than 24 hours after surgery). The incidence is variable.
Mortality post-tonsillectomy is an uncommon event (choice E).
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