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ER Board practice questions

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Question 1Cardiovascular Emergencies

A 58-year-old man has 45 minutes of crushing chest pain. ECG shows 2 mm ST elevation in leads V2 through V4. Which diagnosis is most likely?

  1. Anterior ST-elevation myocardial infarction Correct answer.
  2. Acute pericarditis with diffuse ST elevation
  3. Unstable angina without myocardial injury
  4. Pulmonary embolism with right heart strain

Explanation

ST elevation in contiguous precordial leads V2-V4 localizes to the anterior wall and, with typical ischemic pain, meets STEMI criteria. Unstable angina does not cause ST elevation, and pericarditis usually produces diffuse changes with PR depression. Pulmonary embolism can cause right-heart strain but not localized anterior ST elevation.

Question 2Cardiovascular Emergencies

Which physical finding most strongly supports acute aortic dissection?

  1. Pain relief with nitroglycerin
  2. Bilateral equal radial pulses
  3. Interarm blood pressure difference Correct answer.
  4. S3 gallop on auscultation

Explanation

A significant interarm blood pressure difference reflects subclavian artery involvement and is a classic dissection finding. Equal pulses do not exclude dissection, nitroglycerin relief is more typical of ischemic pain, and an S3 gallop suggests heart failure.

Question 3Cardiovascular Emergencies

A 45-year-old woman has sudden dyspnea and pleuritic chest pain 3 days after hip surgery. HR is 118, BP 110/70, and SpO2 is 90%. What is the most appropriate initial diagnostic test?

  1. Ventilation-perfusion scan
  2. CT pulmonary angiography Correct answer.
  3. D-dimer assay
  4. Chest radiograph

Explanation

The postoperative state, tachycardia, and hypoxia create a high pretest probability of pulmonary embolism, so CT pulmonary angiography is the preferred diagnostic study. D-dimer is less useful when pretest probability is high. Chest radiography is supportive but not diagnostic, and V/Q scanning is an alternative when contrast is contraindicated.

Question 4Cardiovascular Emergencies

Which triad is classically associated with cardiac tamponade?

  1. Pleuritic pain, friction rub, and diffuse ST elevation
  2. Hypotension, muffled heart sounds, and JVD Correct answer.
  3. Hypertension, bradycardia, and irregular respirations
  4. Fever, murmur, and petechiae

Explanation

Beck triad consists of hypotension, muffled heart sounds, and jugular venous distention due to impaired diastolic filling. Fever, murmur, and petechiae suggest endocarditis; hypertension with bradycardia and irregular respirations is Cushing triad; friction rub with diffuse ST elevation suggests pericarditis.

Question 5Cardiovascular Emergencies

A patient with atrial fibrillation at 180 beats/min has hypotension and altered mental status. What is the most appropriate next step?

  1. Urgent synchronized cardioversion Correct answer.
  2. Observation with repeat ECG in 1 hour
  3. Oral digoxin loading
  4. Intravenous diltiazem

Explanation

Atrial fibrillation with hemodynamic instability requires urgent synchronized cardioversion rather than rate-control medication. Diltiazem can worsen hypotension, digoxin acts too slowly, and observation is unsafe in an unstable patient.

Question 6Cardiovascular Emergencies

A 72-year-old man with acute severe dyspnea has crackles to the apices, frothy sputum, and SpO2 84%. He is hypertensive and agitated. Which initial intervention is most appropriate?

  1. Intravenous metoprolol
  2. NIPPV with nitroglycerin Correct answer.
  3. Rapid intravenous fluid bolus
  4. High-dose oral verapamil

Explanation

Acute hypertensive cardiogenic pulmonary edema with hypoxemia is treated with noninvasive positive-pressure ventilation and vasodilators to reduce preload and afterload. Fluid bolus worsens congestion, and beta-blockers or calcium channel blockers can depress contractility and cause hypotension.

Question 7Cardiovascular Emergencies

A 30-year-old has sharp chest pain that worsens when supine and improves leaning forward. ECG shows diffuse ST elevation and PR depression. What is the most likely diagnosis?

  1. Acute pericarditis Correct answer.
  2. Pulmonary embolism
  3. ST-elevation myocardial infarction
  4. Aortic dissection

Explanation

Positional pleuritic pain with diffuse ST elevation and PR depression is classic for acute pericarditis. STEMI usually produces localized contiguous ST elevation, while pulmonary embolism and aortic dissection do not cause this ECG pattern.

Question 8Cardiovascular Emergencies

Which hemodynamic pattern is most consistent with cardiogenic shock?

  1. Wide pulse pressure with warm extremities
  2. Elevated pulmonary capillary wedge pressure with low cardiac index Correct answer.
  3. Low central venous pressure with low pulmonary capillary wedge pressure
  4. High cardiac index with low systemic vascular resistance

Explanation

Cardiogenic shock reflects pump failure with elevated filling pressures and reduced cardiac output. Low filling pressures suggest hypovolemia, high cardiac index with low systemic resistance suggests distributive shock, and warm extremities suggest vasodilation.

Question 9Cardiovascular Emergencies

A 64-year-old with NSTEMI has ongoing chest pain, dynamic ST depression, and elevated troponin. PCI is available. What is the preferred management strategy?

  1. Immediate fibrinolysis followed by conservative care
  2. Discharge with aspirin and outpatient stress testing
  3. Early invasive coronary angiography within 24 hours Correct answer.
  4. Coronary CT angiography before any antiplatelet therapy

Explanation

NSTEMI with high-risk features such as ongoing pain and dynamic ECG changes benefits from an early invasive strategy within 24 hours. Fibrinolysis is not indicated for NSTEMI, and discharge or delayed CT imaging would inappropriately delay definitive care.

Question 10Cardiovascular Emergencies

A patient with STEMI arrives at a hospital without PCI capability. Symptom onset was 2 hours ago, and transfer for PCI would take 3 hours. There are no contraindications. What is the best reperfusion strategy?

  1. Give fibrinolytic therapy now Correct answer.
  2. Start heparin alone and observe
  3. Obtain cardiac MRI before reperfusion
  4. Wait for transfer and proceed directly to PCI

Explanation

When primary PCI cannot be achieved within 120 minutes of first medical contact and symptoms are within 12 hours, fibrinolysis is indicated if there are no contraindications. Waiting 3 hours exceeds the acceptable PCI delay, and heparin alone does not reperfuse the occluded artery.

Question 11Cardiovascular Emergencies

A patient with confirmed Stanford type A aortic dissection has HR 102 and BP 180/100. Which medication should be started first while awaiting surgery?

  1. Oral nifedipine
  2. Intravenous esmolol Correct answer.
  3. Intravenous furosemide
  4. Intravenous hydralazine

Explanation

Beta-blockade is started first to reduce heart rate and dP/dt, followed by a vasodilator if needed. Hydralazine and nifedipine can cause reflex tachycardia and increase shear stress, while furosemide does not treat the underlying dissection.

Question 12Cardiovascular Emergencies

A 60-year-old with confirmed pulmonary embolism has BP 78/50, HR 130, and lactate 4.2 mmol/L. What is the most appropriate immediate treatment?

  1. Observation with serial troponins
  2. Systemic thrombolysis Correct answer.
  3. Inferior vena cava filter placement
  4. Oral rivaroxaban alone

Explanation

Hypotension defines high-risk pulmonary embolism, and systemic thrombolysis is indicated unless contraindicated. Oral anticoagulation alone is insufficient, IVC filters are reserved for selected anticoagulation contraindications, and observation is unsafe.

Question 13Cardiovascular Emergencies

A 78-year-old is hypotensive and confused. ECG shows complete heart block with a ventricular rate of 32. Atropine has no effect. What is the next best step?

  1. Intravenous adenosine
  2. Transcutaneous pacing Correct answer.
  3. Synchronized cardioversion
  4. Sublingual nitroglycerin

Explanation

Symptomatic complete heart block unresponsive to atropine requires transcutaneous pacing while definitive pacing is arranged. Adenosine and cardioversion treat tachyarrhythmias, and nitroglycerin may worsen hypotension.

Question 14Cardiovascular Emergencies

A patient has a regular wide-complex tachycardia at 170 beats/min, BP 118/72, and no chest pain or altered mental status. What is the most appropriate pharmacologic treatment?

  1. Intravenous amiodarone Correct answer.
  2. Intravenous verapamil
  3. Subcutaneous epinephrine
  4. Oral digoxin

Explanation

Wide-complex tachycardia of uncertain origin should be treated as ventricular tachycardia; amiodarone is appropriate in a stable patient. Verapamil can cause hemodynamic collapse in VT, digoxin is not antiarrhythmic here, and epinephrine worsens tachycardia.

Question 15Cardiovascular Emergencies

A 28-year-old has sudden palpitations, HR 190, BP 120/76, and a regular narrow-complex tachycardia. Vagal maneuvers fail. What is the next best drug?

  1. Intravenous atropine
  2. Intravenous adenosine Correct answer.
  3. Intravenous metoprolol
  4. Intravenous amiodarone

Explanation

Stable regular narrow-complex SVT after failed vagal maneuvers is treated with adenosine. Amiodarone is not first-line, metoprolol is slower and an alternative, and atropine would worsen tachycardia.

Question 16Cardiovascular Emergencies

A patient has BP 220/130 with acute pulmonary edema. What is the appropriate initial goal for mean arterial pressure reduction?

  1. MAP reduction of 20-25% in first hour Correct answer.
  2. Lower systolic blood pressure to 90 mm Hg immediately
  3. Reduce by 50% within 1 hour
  4. Reduce to normal within 10 minutes

Explanation

In hypertensive emergency with end-organ damage, mean arterial pressure is lowered about 20-25% in the first hour to avoid hypoperfusion. Rapid normalization can cause ischemia, 50% reduction is too aggressive, and targeting systolic 90 mm Hg is excessive.

Question 17Cardiovascular Emergencies

A 68-year-old with acute decompensated heart failure has BP 190/110, crackles, and severe dyspnea. Which agent is most appropriate initially?

  1. Rapid normal saline bolus
  2. Intravenous nitroglycerin Correct answer.
  3. Oral metoprolol
  4. Intravenous phenylephrine

Explanation

Hypertensive acute heart failure benefits from vasodilators such as nitroglycerin to reduce preload and afterload. Fluid bolus and phenylephrine worsen pulmonary congestion, and beta-blockade is not an initial therapy in decompensated heart failure.

Question 18Cardiovascular Emergencies

A 35-year-old with acute idiopathic pericarditis has no high-risk features. What is the first-line treatment?

  1. Immediate pericardiocentesis
  2. Broad-spectrum antibiotics
  3. NSAIDs plus colchicine Correct answer.
  4. Fibrinolysis

Explanation

Acute idiopathic pericarditis is treated with NSAIDs and colchicine to relieve inflammation and prevent recurrence. Fibrinolysis is for STEMI, antibiotics are for purulent pericarditis, and pericardiocentesis is reserved for tamponade or diagnostic indications.

Question 19Cardiovascular Emergencies

A patient remains in ventricular fibrillation after a second defibrillation and 2 minutes of CPR. Which medication is most appropriate?

  1. Epinephrine 1 mg IV push
  2. Atropine 1 mg IV push
  3. Sodium bicarbonate 1 mEq/kg IV
  4. Amiodarone 300 mg IV bolus Correct answer.

Explanation

For shock-refractory ventricular fibrillation, amiodarone is recommended after the second shock. Epinephrine is typically given earlier in the cycle, atropine is not used for VF, and sodium bicarbonate is not routine.

Question 20Cardiovascular Emergencies

A patient with beta-blocker overdose has HR 38, BP 80/50, and altered mental status. What is the best antidote?

  1. Naloxone
  2. Flumazenil
  3. High-dose glucagon Correct answer.
  4. Atropine only

Explanation

High-dose glucagon bypasses beta-blockade by increasing cyclic AMP and is the preferred antidote for symptomatic beta-blocker toxicity. Naloxone and flumazenil reverse opioids and benzodiazepines, respectively, and atropine alone may be insufficient.

Question 21Cardiovascular Emergencies

A trauma patient with penetrating chest injury is periarrest with ultrasound-confirmed tamponade. While preparing for definitive thoracotomy, which intervention is most appropriate?

  1. Needle thoracostomy
  2. IVC filter
  3. Pericardial window
  4. Pericardiocentesis Correct answer.

Explanation

Pericardiocentesis can temporarily relieve tamponade physiology while operative thoracotomy is being arranged. Needle thoracostomy treats tension pneumothorax, pericardial window is operative, and IVC filters are unrelated to acute traumatic tamponade.

Question 22Cardiovascular Emergencies

A patient with STEMI symptoms also has sudden tearing chest pain, unequal arm pulses, and a widened mediastinum. Which therapy is most dangerous before aortic imaging?

  1. Aspirin
  2. Oxygen
  3. IV access
  4. Fibrinolysis Correct answer.

Explanation

Fibrinolysis in undiagnosed aortic dissection can cause catastrophic hemorrhage and should be withheld until dissection is excluded when suggestive features are present. Aspirin, oxygen, and IV access are supportive and do not carry the same catastrophic risk.

Question 23Cardiovascular Emergencies

A patient with high-risk pulmonary embolism and active intracranial hemorrhage cannot receive thrombolysis. What is the best treatment?

  1. Catheter-directed therapy or surgical embolectomy Correct answer.
  2. Observation
  3. Unfractionated heparin alone
  4. Inferior vena cava filter alone

Explanation

For high-risk PE with an absolute contraindication to systemic thrombolysis, catheter-directed therapy or surgical embolectomy is recommended. Anticoagulation alone is insufficient in shock, IVC filters do not remove existing clot, and observation is unsafe.

Question 24Cardiovascular Emergencies

A dialysis patient has bradycardia, peaked T waves, and QRS 160 ms. Which treatment is most urgent?

  1. Intravenous calcium gluconate Correct answer.
  2. Oral sodium polystyrene sulfonate
  3. Intravenous magnesium sulfate
  4. Intravenous furosemide

Explanation

Hyperkalemia with a widened QRS is a cardiac emergency; intravenous calcium stabilizes the myocardium immediately. Furosemide and potassium binders lower potassium slowly, and magnesium is used for hypomagnesemia or torsades de pointes.

Question 25Cardiovascular Emergencies

After ROSC from ventricular fibrillation, a patient is comatose and hypotensive. Which ventilator strategy is most appropriate?

  1. Titrate to SpO2 92-98% and PaCO2 35-45 mm Hg Correct answer.
  2. Maintain FiO2 at 100% regardless of SpO2
  3. Ventilate at 20 breaths/min to PaCO2 25 mm Hg
  4. Withhold vasopressors unless SBP is below 70 mm Hg

Explanation

Post-arrest care should avoid hyperoxia and hypocapnia by targeting normal oxygenation and ventilation while treating hypotension. Hyperventilation causes cerebral vasoconstriction, 100% oxygen risks hyperoxia, and withholding vasopressors is inappropriate for hypotension.

Question 26Respiratory and Thoracic Emergencies

Which is the most appropriate immediate intervention for a patient with suspected tension pneumothorax and hemodynamic instability?

  1. CT scan of the chest with contrast
  2. Portable chest radiograph to confirm the diagnosis
  3. Needle decompression of the chest Correct answer.
  4. Observation with serial vital signs

Explanation

Tension pneumothorax is a clinical diagnosis, and treatment must not be delayed for imaging. Immediate needle decompression, followed by tube thoracostomy, relieves intrathoracic pressure and restores venous return. Waiting for a radiograph or CT in an unstable patient increases the risk of cardiac arrest.

Question 27Respiratory and Thoracic Emergencies

In acute severe asthma, which medication is the first-line bronchodilator?

  1. Oral montelukast
  2. Inhaled ipratropium alone
  3. Intravenous theophylline
  4. Inhaled albuterol Correct answer.

Explanation

Inhaled short-acting beta-2 agonists such as albuterol are the first-line treatment for acute asthma because they produce rapid bronchodilation. Ipratropium is added as an adjunct in severe cases, and systemic corticosteroids are given early. Montelukast and theophylline are not first-line acute therapies.

Question 28Respiratory and Thoracic Emergencies

What oxygen saturation target should be used for most patients with an acute COPD exacerbation?

  1. 94% to 98%
  2. 88% to 92% Correct answer.
  3. 98% to 100%
  4. 85% to 87%

Explanation

In COPD exacerbation, titrated oxygen to a saturation of 88% to 92% reduces the risk of hypercapnia and respiratory acidosis while maintaining adequate oxygenation. Higher targets can worsen carbon dioxide retention in susceptible patients. The 88% to 92% target is also used in many patients with chronic hypercapnic COPD.

Question 29Respiratory and Thoracic Emergencies

Which electrocardiographic finding is most common in acute pulmonary embolism?

  1. Sinus tachycardia Correct answer.
  2. S1Q3T3 pattern
  3. Atrial fibrillation
  4. Peaked T waves

Explanation

Sinus tachycardia is the most frequent ECG abnormality in acute pulmonary embolism and reflects increased sympathetic tone and right ventricular strain. The classic S1Q3T3 pattern is much less common and is neither sensitive nor specific. Atrial fibrillation and peaked T waves can occur but are not the most common findings.

Question 30Respiratory and Thoracic Emergencies

What is the most common pathogen in community-acquired pneumonia?

  1. Streptococcus pneumoniae Correct answer.
  2. Legionella pneumophila
  3. Haemophilus influenzae
  4. Mycoplasma pneumoniae

Explanation

Streptococcus pneumoniae remains the most commonly identified cause of community-acquired pneumonia in adults. Atypical organisms such as Mycoplasma and Legionella are important but less frequent overall. Empiric therapy therefore usually includes coverage for pneumococcus.

Question 31Respiratory and Thoracic Emergencies

Which symptom is most characteristic of croup?

  1. Expiratory wheezing with prolonged expiration
  2. Barking cough with inspiratory stridor Correct answer.
  3. Drooling and tripod positioning
  4. Sudden onset of unilateral wheeze

Explanation

Croup typically presents with a barking seal-like cough, hoarseness, and inspiratory stridor due to subglottic edema. Drooling and tripod positioning suggest epiglottitis, which is a different and more urgent airway emergency. Expiratory wheezing and unilateral wheeze point toward bronchiolitis or a foreign body.

Question 32Respiratory and Thoracic Emergencies

A child with high fever, drooling, and a muffled voice is most likely to have which condition?

  1. Bronchiolitis
  2. Croup
  3. Foreign body aspiration
  4. Epiglottitis Correct answer.

Explanation

The combination of high fever, drooling, muffled voice, and toxic appearance suggests epiglottitis, which can rapidly obstruct the airway. Croup usually causes a barking cough without drooling. Foreign body aspiration and bronchiolitis have different clinical features.

Question 33Respiratory and Thoracic Emergencies

Which finding defines a flail chest?

  1. Paradoxical motion of a chest segment Correct answer.
  2. Subcutaneous emphysema over the chest wall
  3. Absent breath sounds on one side
  4. Crepitus over the clavicle

Explanation

Flail chest occurs when multiple adjacent ribs are fractured in more than one place, creating a free segment that moves paradoxically during respiration. The underlying pulmonary contusion often determines the severity of respiratory failure. Subcutaneous emphysema and absent breath sounds suggest other injuries.

Question 34Respiratory and Thoracic Emergencies

A 24-year-old tall, thin man has sudden pleuritic chest pain and a 3-cm apical pneumothorax on chest radiograph. He is stable and mildly short of breath. What is the most appropriate management?

  1. Aspiration or tube thoracostomy Correct answer.
  2. Noninvasive positive pressure ventilation
  3. Immediate thoracotomy
  4. Observation without intervention

Explanation

A symptomatic primary spontaneous pneumothorax larger than 2 cm or with significant symptoms is treated with simple aspiration or a small-bore chest tube. Observation alone is reserved for small, asymptomatic pneumothoraces. Thoracotomy is not indicated acutely unless there is persistent air leak or recurrent disease.

Question 35Respiratory and Thoracic Emergencies

Massive hemoptysis is conventionally defined as bleeding of at least what volume?

  1. 2000 mL in 24 hours
  2. 600 mL in 24 hours Correct answer.
  3. 100 mL in 24 hours
  4. 1000 mL in 24 hours

Explanation

Massive hemoptysis is commonly defined as more than 600 mL of blood in 24 hours, although definitions vary and airway compromise matters more than absolute volume. Even smaller volumes can be life-threatening if they impair gas exchange. Management focuses on airway protection, localization, and bleeding control.

Question 36Respiratory and Thoracic Emergencies

A hemodynamically stable patient has high pretest probability for pulmonary embolism. Which test is most appropriate for confirmation?

  1. CT pulmonary angiography Correct answer.
  2. Chest radiograph
  3. Transthoracic echocardiography
  4. D-dimer assay

Explanation

CT pulmonary angiography is the preferred confirmatory test in hemodynamically stable patients with high pretest probability. D-dimer is useful mainly to exclude PE in low or intermediate probability patients, and a normal chest radiograph does not exclude PE. Echocardiography may show right heart strain but is not definitive for diagnosis.

Question 37Respiratory and Thoracic Emergencies

Which criterion is part of the Berlin definition of acute respiratory distress syndrome?

  1. PaO2/FiO2 greater than 400
  2. PaO2/FiO2 ≤300 with PEEP ≥5 cm H2O Correct answer.
  3. Pulmonary capillary wedge pressure above 18 mm Hg
  4. Unilateral infiltrate on chest imaging

Explanation

The Berlin definition requires acute onset, bilateral opacities on imaging, a PaO2/FiO2 ratio of 300 or less with PEEP of at least 5 cm H2O, and respiratory failure not fully explained by cardiac failure. Unilateral infiltrates and high filling pressures point away from ARDS. The ratio is used to grade severity.

Question 38Respiratory and Thoracic Emergencies

A patient with severe asthma exacerbation remains wheezing despite repeated albuterol, ipratropium, and systemic steroids. Which adjunct is most appropriate next?

  1. Intravenous furosemide
  2. Oral prednisone
  3. Inhaled salmeterol
  4. Intravenous magnesium sulfate Correct answer.

Explanation

Intravenous magnesium sulfate is recommended as an adjunct in severe asthma that responds poorly to standard bronchodilators and steroids. It relaxes bronchial smooth muscle and may reduce the need for intubation. Long-acting beta-agonists and diuretics are not acute rescue therapies.

Question 39Respiratory and Thoracic Emergencies

Which finding is the best indication for noninvasive ventilation in a COPD exacerbation?

  1. Systolic blood pressure of 70 mm Hg
  2. Copious secretions with weak cough
  3. pH 7.45 with hyperventilation
  4. pH 7.28 with hypercapnia Correct answer.

Explanation

Noninvasive ventilation is indicated for COPD exacerbation with respiratory acidosis, typically a pH below 7.35 with hypercapnia, while the patient is awake and cooperative. Hypotension and inability to protect the airway or clear secretions are contraindications. Hyperventilation with alkalosis is not an indication.

Question 40Respiratory and Thoracic Emergencies

A patient on positive pressure ventilation suddenly becomes hypotensive. Which finding most suggests tension pneumothorax?

  1. Rising peak pressure and unilateral silence Correct answer.
  2. Bilateral crackles
  3. Fever with purulent sputum and leukocytosis
  4. Decreased peak airway pressure during ventilation

Explanation

In a ventilated patient, tension pneumothorax causes rising peak airway pressures and unilateral absent breath sounds, often with hypotension and hypoxemia. Positive pressure worsens the intrathoracic pressure and impairs venous return. Immediate decompression is required.

Question 41Respiratory and Thoracic Emergencies

An elderly patient has three rib fractures and is in severe pain but has adequate oxygenation. Which management most reduces the risk of pneumonia?

  1. Prophylactic antibiotics
  2. Analgesia and incentive spirometry Correct answer.
  3. Routine intubation and mechanical ventilation
  4. Strict bed rest with minimal activity

Explanation

Adequate analgesia and incentive spirometry encourage deep breathing and coughing, reducing atelectasis and pneumonia after rib fractures. Strict bed rest promotes pulmonary complications, and prophylactic antibiotics are not routinely indicated. Intubation is reserved for respiratory failure.

Question 42Respiratory and Thoracic Emergencies

A patient with a tracheostomy develops sudden respiratory distress and the inner cannula cannot be suctioned. What is the immediate step?

  1. Increase the suction pressure
  2. Administer nebulized saline
  3. Remove the inner cannula and assess the airway Correct answer.
  4. Deflate the cuff and leave the tube in place

Explanation

The first step in a blocked tracheostomy is to remove the inner cannula, which may relieve obstruction and allows inspection. If obstruction persists, the cuff can be deflated or the tube removed and the patient ventilated via the stoma or face. Suction pressure should not be increased blindly.

Question 43Respiratory and Thoracic Emergencies

A patient develops stridor, urticaria, and hypotension after a bee sting. What is the first-line medication?

  1. Intravenous diphenhydramine
  2. Intramuscular epinephrine Correct answer.
  3. Oral corticosteroids
  4. Inhaled albuterol

Explanation

Intramuscular epinephrine is the first-line treatment for anaphylaxis because it rapidly reverses vasodilation, mucosal edema, and bronchospasm. Antihistamines, corticosteroids, and inhaled bronchodilators are adjuncts and do not replace epinephrine. Delay in epinephrine is associated with worse outcomes.

Question 44Respiratory and Thoracic Emergencies

A patient found unconscious in a house fire has carboxyhemoglobin of 30%. Which treatment is most appropriate?

  1. High-flow 100% oxygen Correct answer.
  2. Hyperbaric oxygen for all patients
  3. Nasal cannula oxygen at 2 L/min
  4. Intravenous methylene blue

Explanation

High-flow 100% oxygen is the initial treatment for carbon monoxide poisoning because it shortens the half-life of carboxyhemoglobin. Hyperbaric oxygen is considered for selected severe cases such as neurologic impairment, syncope, or pregnancy, not for every patient. Methylene blue is used for methemoglobinemia.

Question 45Respiratory and Thoracic Emergencies

Which finding after smoke inhalation most strongly suggests the need for early intubation?

  1. Mild cough
  2. PaO2 of 90 mm Hg on room air
  3. Clear breath sounds
  4. Hoarseness, stridor, and soot in the oropharynx Correct answer.

Explanation

Hoarseness, stridor, and soot in the oropharynx suggest upper airway edema from thermal or chemical injury, which can progress rapidly and obstruct the airway. Early intubation should be considered before edema makes laryngoscopy difficult. Normal oxygen saturation does not exclude serious airway injury.

Question 46Respiratory and Thoracic Emergencies

A patient is coughing large amounts of blood from the right lung and is hypoxic. Which measure best protects the airway while awaiting definitive therapy?

  1. Intravenous heparin
  2. Bleeding side down, secure airway Correct answer.
  3. Immediate chest tube insertion
  4. Bleeding side up and observe

Explanation

Positioning the patient with the bleeding lung down reduces spillover of blood into the unaffected lung, and early airway control protects against asphyxiation. Definitive therapy may include bronchoscopy, embolization, or surgery. Chest tubes and heparin do not address airway hemorrhage.

Question 47Respiratory and Thoracic Emergencies

Which ventilator strategy improves survival in acute respiratory distress syndrome?

  1. Permissive hyperoxia with FiO2 of 1.0
  2. Tidal volume of 6 mL/kg predicted body weight Correct answer.
  3. Tidal volume of 12 mL/kg predicted body weight
  4. High tidal volume with low PEEP

Explanation

Lung-protective ventilation with a tidal volume of about 6 mL/kg predicted body weight and adequate PEEP reduces ventilator-induced lung injury and improves survival in ARDS. Higher tidal volumes increase barotrauma and mortality. Hyperoxia is avoided because it can cause oxygen toxicity.

Question 48Respiratory and Thoracic Emergencies

A patient with confirmed pulmonary embolism is hypotensive and has signs of shock. Which treatment is most appropriate?

  1. Oral anticoagulation alone
  2. Inferior vena cava filter
  3. Observation with serial troponins
  4. Systemic thrombolysis Correct answer.

Explanation

Hemodynamically unstable pulmonary embolism is treated with systemic thrombolysis or catheter-directed therapy to rapidly reduce clot burden and improve right ventricular function. Anticoagulation alone is insufficient in shock, and IVC filters are reserved for contraindications to anticoagulation or recurrent embolism. Observation is inappropriate.

Question 49Respiratory and Thoracic Emergencies

After chest tube placement for trauma, a large persistent air leak continues despite suction. Which injury is most likely?

  1. Diaphragmatic rupture
  2. Pulmonary contusion
  3. Tracheobronchial injury Correct answer.
  4. Esophageal rupture

Explanation

A large, persistent air leak after tube thoracostomy suggests a major bronchopleural fistula, such as a tracheobronchial injury. These injuries may also cause massive subcutaneous emphysema and difficulty ventilating. Pulmonary contusion and diaphragmatic rupture do not typically cause persistent large air leaks.

Question 50Respiratory and Thoracic Emergencies

A patient with acute asthma becomes drowsy with minimal wheezing and a silent chest. What does this finding indicate?

  1. Pneumonia
  2. Mild exacerbation improving
  3. Impending respiratory failure Correct answer.
  4. Pleural effusion

Explanation

A silent chest in acute asthma indicates minimal air movement and impending respiratory failure, often requiring intubation and mechanical ventilation. Drowsiness is a sign of hypercapnia and exhaustion. Improvement is associated with reduced distress and improved air movement, not silence.