480 Emergency Medicine
429.The answer is b.(Rosen, pp 801-812.)Please see explanation in previous
question.
430.The answer is e.(Rosen, pp 2035-2048.)This patient is an otherwise
healthy male with no reason to have congestive heart failure (CHF), renal
failure, hepatic failure, or cardiomyopathy. Instead, he is an avid mountain-
climber,which should hint at acute mountain sickness (AMS)in this
clinical scenario. Early on, symptoms may mimic an acute viral syndrome
with nausea, vomiting, headache, and anorexia. However, these symptoms
progress to include peripheral edema, oliguria, retinal hemorrhages, and
finally high-altitude pulmonary or cerebral edema.The initial treatment for
all of these conditions across the spectrum of AMS, include gradual descent.
A descent of 1500 to 3000 ft reverses high-altitude sickness in most cases.
Supplementaloxygenis indicated in all cases. Diuretics, such as acetazolamide
have been proven effective not only for treatment but for prophylaxis.
Symptomatic treatment for vomiting and headache may also be indicated.
Hyperbaric oxygen therapy is indicated in severe cases. Risk factors for AMS
include, but are not limited to, rapid ascent, chronic obstructive pulmonary
disease (COPD), sickle-cell disease, cold exposure, heavy exertion, and sleeping
at higher altitudes.
Furosemide (a)and Hydrochlorothiazide (b)are indicated in CHF
and hypertension. Bumetanide (c)is a more potent loop diuretic, also not
indicated. Fosinopril (d)is an angiotensin-converting enzyme (ACE) inhibitor.
431.The answer is b.(Rosen, pp 2020-2033.)This patient is suffering
from decompression sickness,more commonly known as “the bends.”
This term refers to a spectrum of states whereupon bubbles of nitrogengas col-
lect in the blood and tissues. To help illustrate, picture a bottle of soda
being opened, allowing the bubbles to rapidly come out of the solution to
the top. Clinically, the degree of collection is a result of the depth and
length of the dive. Other risk factors include inherent fatigue, heavy exertion,
dehydration, and flying after a dive. A patent foramen ovale may also prove
to be dangerous in causing gas bubbles to embolize to the arterial system.
Decompression sickness can progress from its initial musculoskeletal involve-
ment to include the cardiovascular, respiratory, and central nervous system
(CNS). Divers should ascend in a slow, gradual manner to avoid to collection
of nitrogen gas in these tissues. Transport to the nearest hyperbaric chamber
is the treatment of choice. IV fluid hydration and supplemental oxygen may
also be warranted.