212.A 64-year-old woman with a history of depression and hypertension
was found down by her husband and brought in by the paramedics. Her
husband says that she has recently been depressed and expressed thoughts
of suicide. She usually takes fluoxetine for depression and atenolol for
hypertension. On arrival, the patient is obtunded, but responds to pain and
is maintaining her airway. Her temperature is 98.1°F, BP is 70/40 mm Hg,
HR is 42 beats per minute, RR is 12 breaths per minute, and oxygen satu-
ration is 94% on room air. On examination, her pupils are 3 mm and reac-
tive bilaterally. Lungs are clear to auscultation. Heart is bradycardic, but
regular, with no murmurs, rubs, or gallops. Extremities have no edema. An
ECG shows first-degree AV block at 42 beats per minute, but no ST/T wave
changes. Blood sugar is 112 mg/dL. What is the most specific treatment for
this patient’s ingestion?
a. Fluid bolus
b. Atropine
c. Glucagon
d. Epinephrine
e. Cardiac pacing
213.A 19-year-old man suffers a single gunshot wound to the left chest
and is brought in by his friends. He is complaining of chest pain. On exam-
ination, his temperature is 99°F, BP is 70/40 mm Hg, HR is 140 beats per
minute, RR is 16 breaths per minute, and oxygen saturation is 96% on
room air. He has distended neck veins, but his trachea is not deviated.
Lungs are clear to auscultation bilaterally. Heart sounds are difficult to
appreciate, but you feel a bounding, regular pulse. Abdomen is soft and
nontender. Extremity examination is normal. Two large-bore IV lines are
placed and the patient is given 2 L of normal saline. Chest radiograph
shows a globular cardiac silhouette, but a normal mediastinum and no
pneumothorax. What is the definitive management of this patient?
a. Intubation
b. Tube thoracostomy
c. Pericardiocentesis
d. Thoracotomy
e. Blood transfusion
218 Emergency Medicine