weakness, his ECG is consistent with life-threatening hyperkalemia and
needs to be addressed emergently. A head CT scan is not required at this
time.(e)Checking urine ketones is an important step in this individual’s
workup to evaluate for diabetic ketoacidosis. However, it should wait until
the patient is stabilized.
14.The answer is a.(Rosen, pp 1234-1236.)The patient most likely has a
partial or complete obstruction in his lower esophagussecondary to the
steak he ate. This usually occurs near the gastroesophageal junction.
Administration of glucagonmay cause enough relaxation of the esophageal
smooth muscleto allow passage of the bolus in approximately 50% of
patients. Its relaxant effect is limited to smooth muscle and therefore can only
be used for impactions in the lower esophagus. If glucagon does not work,
definitive management is with endoscopy.
Meat tenderizer (b),once used for this situation, is now contraindi-
cated secondary to the possibility of perforation as a result of its proteolytic
effect on an inflamed esophageal mucosa. Syrup of ipecac (c)is used rarely
in situations of toxic ingestions. Also, vomiting should be avoided in our
patient to avoid risk of esophageal perforation. The Heimlich maneuver (d)
can be a lifesaving procedure but is not necessary in this patient who is not
in respiratory distress. Respiratory compromise may occur when a foreign
body lodges in the oropharynx, proximal esophagus, or is large enough that
it impinges on the trachea. Laparotomy (e)is not indicated for esophageal
perforations.
15.The answer is e.(Tintinalli, pp 352-353.)Thrombolytic therapy (clot-
busters) can be administered to patients having an acute ST-elevation MI
that is within 6 to 12 hours from symptom onset. Contraindications to fib-
rinolytic therapy are those that increase the risk of hemorrhage. The most
catastrophic complication is intracranial hemorrhage. Absolute contraindi-
cations include:
- Previous hemorrhagic stroke
- Known intracranial neoplasm
- Active internal bleeding (excluding menses)
- Suspected aortic dissection or pericarditis
(a)SBP > 180 mm Hg is a relative contraindication. However, if throm-
bolytics are going to be administered and the patient’s SBP is > 180 mm Hg,
antihypertensive medication can be administered to lower the SBP to below
32 Emergency Medicine