JUST THE FACTS IN EMERGENCY MEDICINE - PART 1 ppt

Clinical Associate Professor of Emergency Medicine Department of Emergency Medicine University of North Carolina School of Medicine at Chapel Hill, Chapel Hill, North Carolina Education

Just the Facts in

EMERGENCY MEDICINE

David M Cline, M.D.

Clinical Associate Professor of Emergency Medicine

Department of Emergency Medicine University of North Carolina School of Medicine

at Chapel Hill, Chapel Hill, North Carolina Education Director, Department of Emergency Medicine

WakeMed, Raleigh, North Caroline

Kansas City, Missouri

Judith E Tintinalli, M.D., M.S.

Professor and Chair Department of Emergency Medicine University of North Carolina at Chapel Hill Chapel Hill, North Carolina

Gabor D Kelen, M.D.

Professor and Chair Department of Emergency Medicine Johns Hopkins University Baltimore, Maryland

J Stephan Stapczynski, M.D.

Professor and Chair Department of Emergency Medicine University of Kentucky Lexington, Kentucky

Just the Facts in

EMERGENCY MEDICINE

David M Cline

O John Ma Judith E Tintinalli Gabor D Kelen

J Stephan Stapczynski

American College of Emergency Physicians

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Section 1

Section 2

v

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vi CONTENTS

Section 4

Section 5

18 Lacerations of the Extremities and Joints

27 Cardiomyopathies, Myocarditis, and Pericardial

CONTENTS vii

Section 7

Section 8

42 Peptic Ulcer Disease and Gastritis

46 Ileitis, Colitis, and Diverticulitis David M Cline 146

49 Jaundice, Hepatic Disorders, and Hepatic Failure

Section 9

54 Emergencies in Dialysis Patients

viii CONTENTS

Section 10

59 Vaginal Bleeding and Pelvic Pain in the

Section 11

72 Bacteremia, Sepsis, and Meningitis in Children

75 Seizures and Status Epilepticus in Children

82 Fluid and Electrolyte Disorders in Children

CONTENTS ix

Section 12

124 Electrical and Lightning Injuries

Section 15

CONTENTS xi

Section 17

143 Seizures and Status Epilepticus in Adults

146 Meningitis, Encephalitis, and Brain Abscess

Section 18

EYE,EAR,NOSE,THROAT,AND

Section 19

xii CONTENTS

Section 21

170 Injuries of the Pelvis, Hip, and Femur

Section 22

MUSCULAR,LIGAMENTOUS,AND

Section 24

Section 25

Computed Tomography and Magnetic Resonance

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Roy Alson, M.D., Assistant Professor, Medical Director, NC Baptist,

AirCare, Wake Forest University School of Medicine, Department ofEmergency Medicine, Winston-Salem, North Carolina (Chapter 44)

Patricia Baines, M.D., Wake Forest University Baptist Medical Center,

North Carolina Baptist Hospital, Department of Emergency Medicine,Winston-Salem, North Carolina (Chapter 41)

Burton Bentley II, M.D., Attending Staff Physician, Department of

Emergency Medicine, Northwest Medical Center, Tucson, Arizona(Chapters 148, 149)

Suzanne Bertollo, M.D., Clinical Instructor, University of North

Caro-lina, Department of Emergency Medicine, Chapel Hill, North CaroCaro-lina,WakeMed, Department of Emergency Medicine, Raleigh, North Caro-lina (Chapter 30)

David F M Brown, M.D., Instructor, Division of Emergency Medicine,

Harvard Medical School, Assistant Chief, Department of EmergencyMedicine, Massachusetts General Hospital, Boston, Massachusetts(Chapter 36)

Lance Brown, M.D., Clinical Assistant Professor, University of

North Carolina, Department of Emergency Medicine, Chapel Hill,North Carolina, WakeMed, Department of Emergency Medicine,Raleigh, North Carolina (Chapters 68, 69, 72, 73, 79, 80, 82,

84, 87)

Martin Carey, M.D., University of Arkansas for Medical Science,

Depart-ment of Emergency Medicine, Little Rock, Arkansas (Chapters 17–19)

David M Cline, M.D., Clinical Associate Professor of Emergency

Medi-cine, Department of Emergency MediMedi-cine, University of North lina School of Medicine at Chapel Hill, Chapel Hill, North Carolina,Education Director, Department of Emergency Medicine, WakeMed,Raleigh, North Carolina (Chapters 1, 2, 4–6, 13, 16, 25–28, 31, 33, 34,

Caro-38, 46, 48, 49, 52–54, 56, 58, 63, 66, 67, 70, 71, 75, 76, 77, 81, 85, 86,

90, 91, 96, 97, 188)

M Chris Decker, M.D., Assistant Professor of Emergency Medicine,

Medical College of Wisconsin, Milwaukee, Wisconsin (Chapters 111,

112, 159, 160)

William R Dennis, Jr., M.D., Chief Resident, Truman Medical Center,

University of Missouri–Kansas City School of Medicine, Kansas City,Missouri (Chapters 150, 153, 163)

xv

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xvi CONTRIBUTORS

Gary Gaddis, M.D., Ph.D., Clinical Associate Professor of Emergency

Medicine, St Luke’s Hospital, University of Missouri–Kansas CitySchool of Medicine, Kansas City, Missouri (Chapters 164, 165, 175, 176)

Alex G Garza, M.D., Assistant Professor of Emergency Medicine,

Tru-man Medical Center, University of Missouri–Kansas City School ofMedicine, Kansas City, Missouri (Chapters 115, 118, 123, 144)

Steven Go, M.D., Assistant Professor of Emergency Medicine, Truman

Medical Center, University of Missouri–Kansas City School of cine, Kansas City, Missouri (Chapter 147)

Medi-Joel L Goldberg, M.D., Department of Emergency Medicine, Franklin

Regional Medical Center, Louisburg, North Carolina (Chapter 93)

Kama Guluma, M.D., St Joseph Mercy Hospital, Department of

Emer-gency Medicine, Ann Arbor, Michigan (Chapter 55)

Geetika Gupta, St Joseph Mercy Hospital, Department of Emergency

Medicine, Ann Arbor, Michigan (Chapter 57)

Gregory Hall, M.D., University of Arkansas for Medical Science, Little

Rock, Arkansas (Chapter 88, 92, 94)

Kent N Hall, M.D., Attending Staff Physician, Department of

Emer-gency Medicine, Mercy Hospital–Fairfield, Fairfield, Ohio (Chapter161)

James Hassen Jr., M.D., Attending Staff Physician, Department of

Emer-gency Medicine, Northwest Medical Center, Tucson, Arizona ters 151, 152, 182)

(Chap-Mark R Hess, M.D., Assistant Professor, Emergency Medicine, Wake

Forest University Baptist Medical Center, Winston-Salem, North lina (Chapter 42)

Caro-Cherri Hobgood, M.D., Assistant Professor, Department of Emergency

Medicine, UNC School of Medicine, UNC Hospitals, Chapel Hill,North Carolina (Chapter 59)

Lance H Hoffman, M.D., Chief Resident, Truman Medical Center,

Uni-versity of Missouri–Kansas City School of Medicine, Kansas City,Missouri (Chapters 100, 109, 113, 177, 181, 187)

Mark E Hoffmann, M.D., Attending Staff Physician, Department of

Emergency Medicine, St Cloud Hospital, St Cloud, Minnesota ters 116, 117, 124, 143, 157, 158, 179)

(Chap-Laura Hopson, M.D., St Joseph Mercy Hospital, Department of

Emer-gency Medicine, Ann Arbor, Michigan (Chapter 65)

Jonathan Jones, M.D., WakeMed, Department of Emergency Medicine,

Raleigh, North Carolina (Chapters 74, 83)

Matthew T Keadey, M.D., Department of Emergency Medicine,

Univer-sity of North Carolina School of Medicine, Chapel Hill, North Carolina(Chapter 32)

Michael P Kefer, M.D., Associate Professor of Emergency Medicine,

Medical College of Wisconsin, Milwaukee, Wisconsin (Chapters 102,

127, 128, 130, 166, 167, 178)

Karen Kinney, M.D., Clinical Associate Professor of Emergency

Medi-cine, East Carolina University, School of MediMedi-cine, Greenville, NorthCarolina (Chapter 60)

Craig E Krausz, M.D., Assistant Professor of Emergency Medicine, St.

Louis University School of Medicine, St Louis, Missouri (Chapters

170, 183, 184–186)

David Krueger, M.D., St Joseph Mercy Hospital, Department of

Emer-gency Medicine, Ann Arbor, Michigan (Chapter 64)

James L Larson, Jr., M.D., Assistant Professor, Assistant Residency

CONTRIBUTORS xvii

Director, University of North Carolina School of Medicine,

Depart-ment of Emergency Medicine, Chapel Hill, North Carolina (Chapters

7, 8)

David L Leader, Jr., D.O., Clinical Instructor, Department of Emergency

Medicine, University of North Carolina, School of Medicine, Chapel

Hill, North Carolina, Wake Medical Center, Department of Emergency

Medicine, Raleigh, North Carolina (Chapters 37, 43)

Maryanne W Lindsay, M.D., F.A.C.E.P., Clinical Assistant Professor,

Wake Forest University School of Medicine, Winston-Salem, North

Carolina (Chapter 47)

O John Ma, M.D., Associate Professor of Emergency Medicine,

Re-search Director and Vice Chair for Faculty Development, Department

of Emergency Medicine, Truman Medical Center, University of

Mis-souri–Kansas City School of Medicine, Kansas City, Missouri

(Chap-ters 108, 146, 155, 162)

Cynthia Madden, M.D., M.P.H., Clinical Associate Professor of

Emer-gency Medicine, University of North Carolina, Chapel Hill, North

Carolina, Director, WakeMed Injury Prevention Center, Raleigh,

North Carolina (Chapters 61, 62)

Jonathan A Maisel, M.D Bridgeport Hospital, Bridgeport, Connecticut,

Associate Program Director, Yale University Emergency Medicine

Residency Program, Assistant Clinical Professor of Surgery

(Emer-gency Medicine), Yale University School of Medicine, New Haven,

Connecticut (Chapter 29)

Keith Mausner, M.D., Attending Staff Physician, Department of

Emer-gency Medicine, Saint Luke’s Hospital, Milwaukee, Wisconsin

(Chap-ters 101, 104, 119–121, 125, 135)

Rodney McCaskill, M.D., WakeMed, Department of Emergency

Medi-cine, Raleigh, North Carolina (Chapter 35)

Damian McHugh, M.B., Ch.B., M.R.C.G.P., Department of Emergency

Medicine, University of North Carolina at Chapel Hill, Chapel Hill,

North Carolina (Chapter 11)

Leslie McKinney, M.D., Priority Care, Cary, North Carolina (Chapters

78, 89)

Chris Melton, M.D., Assistant Professor, University of Arkansas for

Medical Science, University Hospital, Department of Emergency

Med-icine, Little Rock, Arkansas (Chapters 20, 21, 95)

Michael Mikhail, M.D., Clinical Instructor, University of Michigan,

Asso-ciate Chairman, St Joseph Mercy Hospital, Department of Emergency

Medicine, Ann Arbor, Michigan (Chapter 23)

Sandra L Najarian, M.D., Senior Instructor of Emergency Medicine,

Case Western Reserve University, MetroHealth Medical Center,

Cleveland, Ohio (Chapters 98, 126, 131, 134, 141)

James F Palombaro, M.D., WakeMed, Department of Emergency

Medi-cine, Raleigh, North Carolina (Chapters 14, 15)

Joseph J Randolph, M.D., Attending Staff Physician, Department of

Emergency Medicine, Emmanuel Saint Joseph’s–Mayo Health System,

Mankato, Minnesota (Chapters 103, 106, 110, 114, 154)

Thomas A Rebbecchi, M.D., Assistant Professor of Emergency

Medi-cine, Robert Wood Johnson Medical School, Cooper Hospital,

Depart-ment of Emergency Medicine, Camden, New Jersey (Chapters 22, 24)

Mark B Rogers, M.D., Attending Staff Physician, Department of

Emer-gency Medicine, Breech Medical Center, Lebanon, Missouri (Chapters

99, 105, 107, 145, 180)

xviii CONTRIBUTORS

Stefanie R Seaman, M.D., Assistant Professor of Emergency Medicine,

Truman Medical Center, University of Missouri–Kansas City School

of Medicine, Kansas City, Missouri (Chapters 129, 139, 156, 173, 174)

Rawle A Seupaul, M.D., Carolinas Medical Center, Charlotte, North

Carolina (Chapters 9, 10)

Philip B Sharpless, M.D., Assistant Professor of Emergency Medicine,

Medical College of Wisconsin, Milwaukee, Wisconsin (Chapters 138,

149, 142)

Mitchell C Sokolosky, M.D., F.A.C.E.P., Residency Director,

Depart-ment of Emergency Medicine, Wake Forest University School of cine, Winston-Salem, North Carolina (Chapters 39, 40)

Medi-Kathleen F Stevison, M.D., Emergency Physician, Department of

Emer-gency Medicine, Christ Hospital Medical Center, Oak Lawn, Illinois(Chapters 132, 136)

John Sverha, M.D., Attending Staff Physician, Department of Emergency

Medicine, Arlington Hospital, Arlington, Virginia (Chapters 133, 137)

Robert J Vissers, M.D., University of North Carolina School of

Medi-cine, Department of Emergency MediMedi-cine, Chapel Hill, North Carolina(Chapters 3, 51)

Jim Edward Weber, M.D., Assistant Professor, Department of

Emer-gency Medicine, University of Michigan Medical School, Ann Arbor,Michigan, Director of Research, Hurley Medical Center, Flint, Michi-gan (Chapter 12)

Nancy Wick, M.D., Instructor, Pediatrics and Emergency Medicine,

Wake Forest University Baptist Medical Center, Winston-Salem,North Carolina (Chapter 30)

Sarah A Wurster, M.D., Attending Staff Physician, Department of

Emer-gency Medicine, Bethany Medical Center, Kansas City, Kansas ters 168, 169, 171, 172)

In a crunch, when interviewing an eyewitness, Dragnet’s Sgt Joe Friday

would implore, ‘‘Just the facts, ma’am, just the facts.’’ Our textbook, Just

the Facts in Emergency Medicine, aims to provide just that for emergency

physicians who are studying for either the written board (re)certification

examination in emergency medicine or the in-training written

exami-nation

This book has evolved from Judith Tintinalli’s Emergency Medicine:

A Comprehensive Study Guide, fifth edition, which has long been

consid-ered as a premier source for board certification preparation Dr

Tinti-nalli’s first edition of the Study Guide, published in 1978, was designed

to cover the core content of emergency medicine for physicians preparing

for the written board examination Since then, along with the explosive

growth in the field of emergency medicine, the Study Guide has been

expanded to the point where it may be too voluminous to serve as a

rapid review source The other book that has evolved from the Study

Guide, the Companion Handbook, was designed as a streamlined pocket

reference guide for the practicing clinician and contains only the essential

information that is pertinent to the clinical care of the patient in the

emergency department

Each chapter in Just the Facts in Emergency Medicine emphasizes

the key points in the Epidemiology, Pathophysiology, Clinical Features,

Diagnosis and Differential, and Emergency Department Care and

Dispo-sition of the disease entity The bulleted outline for each factual item is

designed to enhance its use as a rapid study aid

We would like to express our deep appreciation to the Just the Facts

in Emergency Medicine chapter authors for their commitment and hard

work in helping to produce this textbook We also are indebted to

numer-ous individuals who assisted us with this project, in particular, we would

like to thank Andrea Seils, Lester A Sheinis, and Richard C Ruzycka

at McGraw-Hill Finally, without the love and encouragement of our

families, this book would not have been possible DMC thanks his wife,

Lisa, and his secretary, Nell; and OJM thanks Natasha, Gabrielle, Sabrina,

Julius, Rebekah, and Elise

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Just the Facts in

EMERGENCY MEDICINE

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Section 1

TEST PREPARATION AND PLANNING

MEDICINE BOARD EXAMS

David M Cline

• The American Board of Emergency Medicine

(ABEM) administers three written exams each

year: the Certification Exam, the Recertification

Exam, and the In-Training Exam For the most

up-to-date information concerning these exams,

review the ABEM web site: www.abem.org.

• The American Board of Osteopathic Emergency

Medicine (ABOEM) administers one certification

examination per year

ABEM WRITTEN CERTIFICATION

EXAM

• The Certification exam is given each year in early

November at several locations throughout the

country; check for test site information at www.

abem.org This exam is usually given the day after

the Recertification exam

• The test consists of approximately 335 questions

and lasts a total of 6 h and 15 min (1.1 min per

question) There is a 60-min break for lunch

• Of the test questions, 15 percent include a pictorial

stimulus, generally during the first portion of

the exam

• The pass/fail criterion is 75 percent correct of

those test items, which are included in the

exami-nation for the purpose of scoring

• Typically, only two-thirds of the test is scored,

with one-third of the test questions representing

new trial content These investigational questions

are compared with standardized questions for

re-1

liability and may be included as scored items thefollowing exam cycle Typically, a question re-quires 2 years from the time of creation to use as

a scored item

• The pass rate for the Certification exam duringthe 1998 exam cycle was 91 percent for first-timetakers with emergency medicine residency train-ing and 73 percent for all others

• Subject matter of the exam is based on the gency Medicine Core Content.1

Emer-• A percentage breakdown of the exam contentcompared to the chapters of this book is listed inTable 1-1 Although many of the questions aredifferent, the content percentages are the same

for all three ABEM written exams Just the Facts

in Emergency Medicine includes several chapters

that include multiple topics, therefore our ters do not precisely correlate to the exam ques-tion content areas

chap-• Compared to the Recertification exam, the fication exam has more pathophysiology-basedquestions Roughly 60 percent of the questionsare management based, many of which require adiagnosis be made from the clinical description.There are 20 percent that are diagnosis based,and 10 percent are pathophysiology based Theremaining 10 percent of questions relate to admin-istrative, emergency medical service (EMS), disas-ter medicine, and miscellaneous issues

Certi-• Certification expires every 10 years

ABEM WRITTEN RECERTIFICATION EXAM

• The Recertification exam is given each year inearly November at several locations throughoutthe country, check for test site information at

Copyright 2001 The McGraw Hill Companies, Inc Click Here for Terms of Use.

2 SECTION 1•TEST PREPARATION AND PLANNING

TABLE 1-1 Percentage Distribution of Test Items by Core Content Category Compared to Chapter Listing of Just the

Facts in Emergency Medicine

WRITTEN EXAM PERCENTAGE NUMBER OF JUST THE FACTS IN EMERGENCY MEDICINE

CONTENT AREA DISTRIBUTION (%) CHAPTERS CHAPTERS REPRESENTED

Abdominal and gastrointestinal dis- 7 15 (7.9%) 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 orders

Cardiovascular disorders 11 15 (7.9%) 4, 5, 9, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 69, 81 Cutaneous disorders 1 2 (1.0%) 151, 152

Endocrine, metabolic, and nutritional 6 8 (4.2%) 6, 78, 79, 82, 127, 128, 129, 130

disorders

Environmental disorders 2 11 (5.8%) 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126 Head, ear, eye, nose, throat dis- 8 8 (4.2%) 16, 70, 83, 138, 147, 148, 149, 150

orders

Hematologic disorders 2 7 (3.7%) 131, 132, 133, 134, 135, 136, 137

Immune system disorders 1 3 (1.6%) 11, 90, 97

Systemic infectious disorders 3 8 (4.2%) 8, 89, 91, 92, 93, 94, 95, 96

Musculoskeletal disorders (nontrau- 3 6 (3.2%) 175, 176, 177, 178, 179, 180

matic)

Nervous system disorders 5 9 (4.7%) 10, 139, 140, 141, 142, 143, 144, 145, 146

Obstetrics and disorders of preg- 2 4 (2.1%) 60, 61, 62, 63

nancy

Pediatric disorders 8 14 (7.4%) 67, 68, 71, 72, 75, 76, 77, 78, 79, 80, 84, 85, 86, 87 Psychobehavioral disorders 3 3 (1.6%) 181, 182, 183

Administrative aspects of emergency 2 3 (1.6%) 184, 185, 189

medicine

Emergency medical services/disaster 3 1 (0.6%) 188

medicine

Clinical pharmacology 2 2.5 (1.3%) 4,* 12, 13, plus various chapters

Procedures/skills 4 10 (5.2%) 3, 14, 15, 17, 18, 19, 20, 21, 186, 187, plus various

chapters

* Chapter content divided between two board exam content areas.

www.abem.org This exam is usually given the day

before the Certification exam

• The test consists of approximately 310 questions

and lasts a total of 5 h and 45 min (1.1 min per

question) There is a 60-min break for lunch

• Of the test questions, 15 percent include a pictorial

stimulus, generally during the first portion of

the exam

• The pass/fail criterion for the Recertification

exam is 75 percent correct of those test items,

which are included in the examination for the

pur-pose of scoring

• Typically, only two-thirds of the test is scored,with one-third of the test questions representingnew trial content These investigational questionsare compared with standardized questions for re-liability and may be included as scored items thefollowing exam cycle

• The pass rate for the Recertification exam duringthe 1998 exam cycle was 95 percent

• Subject matter of the exam is based on the gency Medicine Core Content.1

Emer-• A percentage breakdown of the exam contentcompared to the chapters of this book is listed in

CHAPTER 2•TEST-TAKING TECHNIQUES 3

Table 1-1 Although many of the questions are

different, the content percentages are the same

for all three ABEM written exams Just the Facts

in Emergency Medicine includes several chapters

that include multiple topics, therefore our

chap-ters do not precisely correlate to the exam

ques-tion content areas

• Compared to the Certification exam, the

Recerti-fication exam is more clinically based and has less

pathophysiology-based questions

• Recertification must be accomplished every 10

years to maintain ABEM Board Certification

ABEM IN-TRAINING EXAM

• The In-Training exam is given to all emergency

medicine residents each year in late February

• The test consists of approximately 225 questions

and lasts 4 h and 15 min (1.1 min per question),

given as a single session

• There is no pass/fail criterion; rather, residents

are compared to other residents across the country

at their same level of training Scores for

individ-ual training programs are compared with other

training programs across the country, and this

in-formation is provided to residency program

di-rectors

• Subject matter of the exam is based on the

Emer-gency Medicine Core Content.1

• The target at which all questions are aimed is the

expected knowledge base and experience of an

emergency medicine third-year resident

• A percentage breakdown of the exam content

compared to the chapters of this book is listed in

Table 1-1 Although many of the questions are

different, the content percentages are the same

for all three ABEM written exams Just the Facts

in Emergency Medicine includes several chapters

that include multiple topics, therefore our

chap-ters do not precisely correlate to the exam

ques-tion content areas

AOBEM WRITTEN CERTIFICATION

EXAM

• The certification exam is given the first week of

February each year

• Like the ABEM exams, the subject matter of the

exam comes from the Emergency Medicine Core

Content.1 However, AOBEM adds some testitems drawn from osteopathic principles andpractice

• The percentage breakdown of the exam may bedifferent than that listed in Table 1-1

• AOBEM, like ABEM, uses a preset passing score,but it is not currently published Also, each examcontains nonscored test items that are in the pro-cess of evaluation and standardization

1 American College of Emergency Physicians: Core content

for emergency medicine Ann Emerg Med 29:792–811,

well-STUDY TECHNIQUES

• Begin by setting a schedule to accomplish yourstudy goals and objectives in the time remainingprior to the test Allow time for reading this book,using a question-and-answer book to uncover anygaps in your knowledge base and your final review.Your schedule should be written and checked of-ten to document your progress

• Find a place to study that facilitates concentration,not distraction Hettich found that a single place

of study improved test performance.1

• Begin reading each chapter by glancing over thetopic headings to get an overview of the material.Formulate questions in your mind such as:

1 What etiologic information will help me toidentify the disease?

2 What pathophysiologic concepts will help totreat the disease?

3 What clinical features will help me to identifythe disease?

4 SECTION 1•TEST PREPARATION AND PLANNING

4 What criteria make the diagnosis of the

disease?

5 What are the recommended treatments for

the disease?

• Reading should be an active experience Don’t

turn the exercise into a coloring contest with your

highlighter Write in the margins, circle, underline,

and identify key points

• Review your notes and key points at the end

If you find the material confusing or your

under-standing incomplete, you will need to go to other

sources for additional information, such as the

parent textbook for this review book:

Emer-gency Medicine: A Comprehensive Study Guide,

5th ed

• Last-minute cramming is an inefficient study

method, taxes your energy level, and creates

anxiety.2

PREPARATION IMMEDIATELY

BEFORE THE TEST

• Get plenty of sleep the night before the test

• Arrive at the test site well in advance of the start

time to make sure you know where the exam room

is located and become familiar with the

sur-roundings

• Check the temperature of the exam room so that

you can anticipate proper attire Dress

com-fortably

• Schedule enough time to wake up, dress, and eat

an unhurried breakfast

• Eat an adequate but not heavy breakfast Do the

same for the lunch break

• Bring a photo ID to identify yourself

• Pencils are provided No food (including candy)

is allowed at the exam tables Water is available

in the room If current policy holds, diplomates

taking the recertification exam may find a snack

table and coffee at the back of the room However,

you must consume these nourishments at the back

tables and may not bring them with you to the

table where you test

TAKING THE TEST

• Listen carefully to the instructions given and read

completely any written instructions

• You have 1.1 min per question on the test Make

sure that at any given point you are keeping to

schedule For example, at the 1-h mark, you

should have answered approximately 60

ques-tions However, the pictorial stimulus portion ofthe test is usually first, and these questions takemore time than the remaining questions for mosttest takers

• There is no penalty for guessing on this choice exam

multiple-• Fill in the answer sheet as you go Many authorsrecommend skipping the hard questions and re-turning to them at the end This practice mayleave you without time to revisit the unansweredquestions Skipping items also increases thechances that you will key the answer sheet incor-rectly Study proctors will not allow you extra time

to correct or fill in your answer sheet

• Carefully read the question stem and anticipatethe answer before you read the options listed Ifyou see the choice you anticipate, that answer ismost likely correct

• Read all the answers to check for a more complete

or better answer than the one you anticipate

• Don’t use excessive time on a single question thatpuzzles you Simply make your best guess andmove on Make a note in the test booklet marginand return to the question at the end for furtherconsideration

• Remember that approximately one-third of thetest is not scored (see Chap 1) If you don’t knowthe answer or find the question confusing, it may

be a trial question Don’t loose your confidence

or your momentum

• Learn to identify the incorrect options quickly sothat, if you are forced to guess, you have a betterchance of being correct

• On items that have ‘‘all of the above’’ as an option,

if you are certain that two other answers are rect, you should choose ‘‘all of the above.’’

cor-• Options that include broad generalizations aremore likely to be incorrect

• There is no evidence to support the idea that tion ‘‘C’’ is more likely to be correct than others

op-on ABEM exams

• Use every minute of the test time If you havetime left over, review first the questions you haveidentified as difficult and then use the remainingtime to reread the questions, looking for any mis-interpretations that may have occurred the firsttime through

• Contrary to popular opinion, your ‘‘first guess’’

is not more likely to be correct than a carefullyconsidered reevaluation of the answer.3If, duringthe review process, you find a better answer to aquestion stem, do not hesitate to change yourchoice You have a 57.8 percent chance of chang-ing a wrong answer to a correct one, a 22.2 percentchance of changing a wrong answer to another

CHAPTER 2•TEST-TAKING TECHNIQUES 5

wrong answer, and only a 20.2 percent chance of

changing a correct answer to an incorrect one.3

• Do not spend your lunch break discussing specific

test questions with colleagues This practice could

disqualify you from the test, and it creates more

anxiety, further limiting your performance in the

afternoon Remember, only two-thirds of the test

is scored

• Relax The odds are in your favor And now that

you own this book, you have a concise means to

review the practice of emergency medicine

1 Hettich PI: Learning Skills for College and Career Pacific

Grove, CA: Brooks/Cole, 1992.

2 Zechmeister EB, Nyberg SE: Human Memory: An

Intro-duction to Research and Theory Pacific Grove, CA:

Brooks/Cole, 1982.

3 Benjamin LT, Covell TA, Shallenberger WR: Staying

with initial answers on objective tests: Is it a myth? ing Psychol 11:133, 1984.

Teach-This page intentionally left blank.

• There are four main indications for invasive

air-way management: airair-way protection, ventilation,

oxygenation, and facilitation of therapy

PATHOPHYSIOLOGY

• The upper anatomic airway includes the oral and

nasal cavities down to the larynx The lower

air-way includes the trachea, bronchi, and lungs

• Potentially difficult intubations can be predicted

by the following:

a External features suggestive of difficulty, such

as a beard, obesity, a short neck, a receding

chin, and tracheostomy scars

b Inability to open the mouth three finger

breadths or a thyromental distance less than

three finger breadths

c A relatively large tongue for the oral cavity as

estimated by the inability to visualize more

than the base of the uvula in a cooperative

patient opening the mouth in a sniffing

po-sition.1

d Evidence of upper airway obstruction (see

Ta-ble 3-1)

e Lack of neck mobility This should be assessed

only in patients without a potential C-spine

• The method of airway management is dependent

on the patient, the indications, and the perceivedairway difficulty Options for airway managementinclude bag-valve-mask, tracheal intubation, alter-native noninvasive airways, and surgical airways

• Definitive airway management, if indicated on tial assessment, should not be delayed until theresults for arterial blood gases are received

• Orotracheal intubation is associated with a highersuccess rate and lower complication rate thancompared with nasotracheal intubation.2

EMERGENCY DEPARTMENT CARE AND DISPOSITION

• Orotracheal intubation using rapid-sequence bation (RSI) techniques is the preferred methodfor tracheal intubation.2,3

intu-• A laryngoscope using a number 3 or 4 Macintoshblade or a number 3 Miller (straight) blade is

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8 SECTION 2•RESUSCITATIVE PROBLEMS AND TECHNIQUES

TABLE 3-1 Clinical Manifestations Associated with

Acute Airway Obstruction

Vascular Hematoma

External hemorrhage Hypotension Hemoptysis Laryngotracheal Stridor

Subcutaneous air (massive) Hoarseness

Dysphonia Hemoptysis Pharyngeal and/or hypopharyngeal Subcutaneous air

Hematemesis Dysphagia Sucking wound

sufficient for most adults, depending on size and

intubator preference

• An endotracheal tube with an internal diameter

of 7.5 to 8.0 mm and 8.0 to 8.5 mm is appropriate

for most adult females and males, respectively

• Endotracheal tubes with high-volume,

low-pres-sure cuffs are preferred for the prevention of

aspi-ration and to avoid ischemia of the tracheal

mucosa.4

TABLE 3-2 Sedative Induction Agents

Thiopental 3–5 mg/kg 30–40 s 10–30 min 앗 ICP 앗 BP

Laryngospasm Methohexital 1 mg/kg ⬍1 min 5–7 min 앗 ICP 앗 BP

Short duration Seizures

Laryngospasm Midazolam 0.1 mg/kg 1–2 min 20–30 min Reversible Apnea

Amnesic No analgesia Anticonvulsant Highly variable dose Ketamine 1–2 mg/kg 1 min 5 min Bronchodilator 앖 Secretions

‘‘Dissociative’’ amnesia 앖 ICP

Emergence phenomenon Etomidate 0.3 mg/kg ⬍1 min 10–20 min 앗 ICP Myoclonic excitation

앗 IOP Vomiting Rare 앗 BP No analgesia Propofol 0.5–1.5 mg/kg 20–40 s 8–15 min Antiemetic Apnea

Anticonvulsant 앗 BP

앗 ICP No analgesia Haloperidol 5-mg aliquots 5–10 min Variable Rare 앗 BP Titrate

Dystonia Droperidol 2.5-mg aliquots 5–10 min Variable Rare 앗 BP Titrate

Antiemetic Dystonia

앗 BP Fentanyl 3–8 애g/kg 1–2 min 30–40 min Reversible analgesia Highly variable dose

ICP—variable effects Chest wall rigidity

A : BP ⫽ blood pressure; ICP ⫽ intracranial pressure; IOP ⫽ intraocular pressure.

• The tube ideally is placed 2 cm above the carina.From the corner of the mouth, this is approxi-mately 23 cm in men and 21 cm in women.5

• Patient positioning is critical to successful tion Flexion of the lower neck with extension atthe atlanto-occipital joint aligns the oropharyn-geolaryngeal axes, allowing better glottic visual-ization

intuba-• RSI involves the combined administration of aninduction agent and a neuromuscular blockingagent to facilitate tracheal intubation.2The follow-ing steps are taken:

a Preparation of the patient and equipment andassessment of airway difficulty

b Preoxygenation with 100% oxygen

c Administration of pretreatment agents to bluntadverse responses to RSI in selected patients.The four most commonly used agents are lido-caine, opioids, defasciculating agents, and at-ropine

d Administration of an induction agent (see ble 3-2).6

Ta-e Administration of neuromuscular blockadTa-e.Succinylcholine is the most common agentused because of its rapid onset and short dura-tion of action.2Some adverse effects are unique