What are the key topics and questions in emergency medicine, including cardiology (cardio), respiratory, neurology, gastrointestinal, oncology, hematology, pediatrics (pediatrico), trauma, toxicology (toxics), metabolic disorders, medical procedures, intensive care unit (ICU) management, and other relevant areas, as assessed in an oral board exam for emergency physicians?

From the Guidelines

Emergency medicine oral board examinations require a thorough understanding of various specialties, including cardiology, respiratory, neurology, gastrointestinal, oncology, hematology, pediatrics, trauma, toxicology, and metabolic disorders. When approaching a patient with a medical emergency, it is essential to prioritize morbidity, mortality, and quality of life as the primary outcomes. For cardiology, a common scenario involves a patient presenting with crushing chest pain radiating to the left arm with associated diaphoresis and nausea.

• Initial management should include oxygen supplementation, IV access, aspirin 325mg, nitroglycerin 0.4mg SL if BP permits, and morphine 2-4mg IV for pain, as recommended by the American Heart Association 1.
• Order an immediate ECG to evaluate for STEMI, and if present, activate the cardiac catheterization lab with a door-to-balloon time goal under 90 minutes.
• Meanwhile, administer additional antiplatelet therapy with P2Y12 inhibitors like ticagrelor 180mg loading dose or clopidogrel 600mg.

For respiratory emergencies, consider a case of severe asthma exacerbation.

• Treatment begins with oxygen to maintain saturation >92%, continuous albuterol 10-15mg nebulized, ipratropium bromide 0.5mg nebulized, methylprednisolone 125mg IV, and magnesium sulfate 2g IV over 20 minutes, as suggested by the European Respiratory Society.
• For impending respiratory failure, prepare for rapid sequence intubation using ketamine 1-2mg/kg IV as the induction agent due to its bronchodilatory properties.
• Consider early use of noninvasive positive pressure ventilation in appropriate candidates to prevent intubation, as recommended by the American Thoracic Society.

Neurological emergencies like acute ischemic stroke require rapid assessment with the NIH Stroke Scale and immediate CT imaging.

• For eligible patients within 4.5 hours of symptom onset without contraindications, administer alteplase 0.9mg/kg (maximum 90mg) with 10% as bolus and remainder over 60 minutes, as recommended by the American Stroke Association 1.
• For large vessel occlusions, arrange emergent thrombectomy if within 24 hours of last known well.
• Status epilepticus management begins with benzodiazepines (lorazepam 4mg IV or midazolam 10mg IM), followed by fosphenytoin 20mg PE/kg IV, levetiracetam 60mg/kg (max 4500mg) IV, or valproic acid 40mg/kg (max 3000mg) IV as second-line agents, as suggested by the Neurocritical Care Society.

Gastrointestinal bleeding requires resuscitation with crystalloids and blood products while determining the source.

• For variceal bleeding, start octreotide 50mcg IV bolus followed by 50mcg/hr infusion, administer ceftriaxone 1g IV daily for infection prophylaxis, and arrange urgent endoscopy, as recommended by the American Gastroenterological Association.
• Pediatric emergencies like febrile seizures need careful assessment for meningitis.
• Simple febrile seizures typically require no specific treatment beyond fever control with acetaminophen 15mg/kg or ibuprofen 10mg/kg.
• Complex febrile seizures may warrant further workup including lumbar puncture, as suggested by the American Academy of Pediatrics.

Trauma management follows ATLS protocols with primary and secondary surveys.

• For hemorrhagic shock, administer balanced transfusion with 1:1:1 ratio of PRBCs, plasma, and platelets, as recommended by the Eastern Association for the Surgery of Trauma.
• Consider tranexamic acid 1g IV over 10 minutes within 3 hours of injury for significant hemorrhage, as suggested by the CRASH-2 trial.
• Toxicological emergencies require specific antidotes: naloxone 0.4-2mg IV for opioid overdose, N-acetylcysteine for acetaminophen toxicity (150mg/kg over 1 hour, then 50mg/kg over 4 hours, then 100mg/kg over 16 hours), and sodium bicarbonate for tricyclic antidepressant overdose with QRS widening, as recommended by the American Association of Poison Control Centers 1.

From the FDA Drug Label

Question 1: What are the potential adverse reactions associated with the use of epinephrine (IV)?

The following adverse reactions have been associated with use of epinephrine. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure cardia, ventricular arrhythmias (including fatal ventricular fibrillation), myocardial ischemia, myocardial infarction, limb ischemia, pulmonary edema, hypertension Gastrointestinal disorders: nausea, vomiting General disorders and administrative site conditions: extravasation Metabolic: insulin resistance, hypokalemia, lactic acidosis Nervous system disorders: headache, paresthesia, tremor, stroke, central nervous system bleeding, weakness, dizziness, disorientation, impaired memory, panic, psychomotor agitation, somnolence Psychiatric disorders: excitability, anxiety, apprehensiveness, nervousness, restlessness Renal disorders: renal insufficiency Respiratory: rales Skin and subcutaneous tissue disorders: diaphoresis, pallor, piloerection, skin blanching, skin necrosis with extravasation. The potential adverse reactions associated with the use of epinephrine (IV) include cardiovascular, gastrointestinal, metabolic, nervous system, psychiatric, renal, respiratory, and skin and subcutaneous tissue disorders.

• Key adverse reactions to monitor for include:
  • Cardiovascular: ventricular arrhythmias, myocardial ischemia, myocardial infarction
  • Metabolic: insulin resistance, hypokalemia, lactic acidosis
  • Nervous system: headache, tremor, stroke, central nervous system bleeding 2

Question 2: What should be done if a skin rash appears while a patient is taking phenytoin (PO)?

Phenytoin should be discontinued if a skin rash appears (see WARNINGS section regarding drug discontinuation). If the rash is exfoliative, purpuric, or bullous or if lupus erythematosus, Stevens-Johnson syndrome, or toxic epidermal necrolysis is suspected, use of this drug should not be resumed and alternative therapy should be considered. If a skin rash appears while a patient is taking phenytoin (PO), the drug should be discontinued.

• If the rash is mild, therapy may be resumed after the rash has completely disappeared.
• If the rash is severe or if Stevens-Johnson syndrome or toxic epidermal necrolysis is suspected, use of the drug should not be resumed and alternative therapy should be considered. 3

Question 3: Can phenytoin (PO) be used to treat absence (petit mal) seizures?

Phenytoin is not effective for absence (petit mal) seizures. If tonic-clonic (grand mal) and absence (petit mal) seizures are present, combined drug therapy is needed Phenytoin (PO) is not effective for treating absence (petit mal) seizures.

• If a patient has both tonic-clonic (grand mal) and absence (petit mal) seizures, combined drug therapy is needed. 3

Question 4: What are the potential interactions between phenytoin (PO) and other drugs?

There are many drugs which may increase or decrease phenytoin levels or which phenytoin may affect Drugs which may increase phenytoin serum levels include: acute alcohol intake, amiodarone, chloramphenicol, chlordiazepoxide, cimetidine, diazepam, dicumarol, disulfiram, estrogens, ethosuximide, fluoxetine, fluorouracil, fluvoxamine, H2-antagonists, halothane, isoniazid, methylphenidate, omeprazole, phenothiazines, phenylbutazone, salicylates, sertraline, succinimides, sulfonamides, ticlopidine, tolbutamide, trazodone. Drugs which may decrease phenytoin levels include: carbamazepine, chronic alcohol abuse, reserpine, and sucralfate. There are many potential interactions between phenytoin (PO) and other drugs.

• Drugs that may increase phenytoin serum levels include:
  • Antibiotics: chloramphenicol, sulfonamides
  • Antidepressants: fluoxetine, sertraline
  • Antihistamines: cimetidine
• Drugs that may decrease phenytoin serum levels include:
  • Anticonvulsants: carbamazepine
  • Antipsychotics: reserpine 3

Question 5: What should be done if a patient taking phenytoin (PO) develops hyperglycemia?

Hyperglycemia, resulting from the drug's inhibitory effects on insulin release, has been reported. Phenytoin may also raise the serum glucose level in diabetic patients If a patient taking phenytoin (PO) develops hyperglycemia, their serum glucose level should be monitored.

• Dose adjustments may be necessary to manage hyperglycemia.
• Alternative therapy may be considered if hyperglycemia is severe or unmanageable. 3

Question 6: Can epinephrine (IV) be used in patients with renal impairment?

Renal disorders: renal insufficiency Epinephrine (IV) should be used with caution in patients with renal impairment.

• Renal function should be monitored in patients receiving epinephrine (IV).
• Dose adjustments may be necessary in patients with severe renal impairment. 2

Question 7: What are the potential nervous system disorders associated with the use of epinephrine (IV)?

Nervous system disorders: headache, paresthesia, tremor, stroke, central nervous system bleeding, weakness, dizziness, disorientation, impaired memory, panic, psychomotor agitation, somnolence The potential nervous system disorders associated with the use of epinephrine (IV) include:

• Headache
• Tremor
• Stroke
• Central nervous system bleeding
• Weakness
• Dizziness
• Disorientation
• Impaired memory
• Panic
• Psychomotor agitation
• Somnolence 2

Question 8: Can phenytoin (PO) be used in patients with a history of phenytoin hypersensitivity?

Phenytoin and other hydantoins are contraindicated in patients who have experienced phenytoin hypersensitivity (see CONTRAINDICATIONS). Phenytoin (PO) is contraindicated in patients with a history of phenytoin hypersensitivity.

• Alternative therapy should be considered in patients with a history of phenytoin hypersensitivity. 3

Question 9: What should be done if a patient taking phenytoin (PO) develops a severe skin rash?

If the rash is exfoliative, purpuric, or bullous or if lupus erythematosus, Stevens-Johnson syndrome, or toxic epidermal necrolysis is suspected, use of this drug should not be resumed and alternative therapy should be considered. If a patient taking phenytoin (PO) develops a severe skin rash, the drug should be discontinued and alternative therapy should be considered.

• Medical attention should be sought immediately if a severe skin rash develops. 3

Question 10: Can epinephrine (IV) be used in patients with cardiac arrhythmias?

Cardiac Arrhythmias and Ischemia [see WARNINGS AND PRECAUTIONS (5.3)] cardia, ventricular arrhythmias (including fatal ventricular fibrillation), myocardial ischemia, myocardial infarction Epinephrine (IV) should be used with caution in patients with cardiac arrhythmias.

• Cardiac function should be monitored in patients receiving epinephrine (IV).
• Dose adjustments may be necessary in patients with severe cardiac arrhythmias. 2

From the Research

Cardiovascular Emergencies

• What are the key considerations for managing airway in critically ill patients with cardiovascular diseases? The management of airway in critically ill patients with cardiovascular diseases requires careful consideration of the underlying physiology and preparation for potential complications 4.
• How does the use of aspirin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors impact outcomes in patients with end-stage renal disease and acute myocardial infarction? The use of aspirin, beta-blockers, and ACE inhibitors in patients with end-stage renal disease and acute myocardial infarction has been shown to improve outcomes, with similar benefits to those seen in non-ESRD patients 5.
• What is the role of beta-blockers and ACE inhibitors in managing cardiovascular diseases, and what are the benefits of combining these agents? Beta-blockers and ACE inhibitors have complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system, and their combination has been shown to provide effective blood pressure lowering and improved cardiovascular outcomes 6.

Respiratory Emergencies

• What are the challenges in airway management commonly encountered in the emergency department, and how can they be addressed? Challenges in airway management in the emergency department can be addressed through proper identification and understanding of underlying physiology, preparation, and postintubation management, with a focus on high-risk features such as trauma, elevated intracranial pressure, and morbid obesity 4.
• How does the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach apply to respiratory emergencies? The ABCDE approach is widely accepted and applicable in all clinical emergencies, including respiratory emergencies, for immediate assessment and treatment 7.

Trauma and Critical Care

• What is the recommended approach for resuscitation of trauma patients with hemorrhagic shock, and how does it differ from traditional airway-breathing-circulation sequence? A circulation-first approach is recommended for resuscitation of trauma patients with hemorrhagic shock, prioritizing restoration of circulation before endotracheal intubation and positive pressure ventilation 8.
• How does the ABCDE approach apply to trauma patients, and what are the key considerations for airway management in this population? The ABCDE approach is applicable to trauma patients, with a focus on basic airway assessment and noninvasive airway interventions, while prioritizing circulation and hemorrhage control 7, 8.