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1) A 69-year-old woman is brought to the ED after her husband found her unconscious at home and
could not awaken her. She left a suicide note for her daughter and ingested an unspecified amount of
pills. On arrival, the patient’s vital signs are: blood pressure, 50/22 mm Hg; heart rate, 120 bpm;
respiratory rate, 10 breaths/min; and pulse oximetry, 94% on room air. The patient’s pupils are 6 mm
equally round and reactive to light. Lungs are clear, and heart rate is rapid with no murmurs, rubs, or
gallops. Bowel sounds are decreased. Capillary refill is delayed. Glasgow Coma Scale score is 3.
Fingerstick glucose level is 125 mg/dL. The patient’s electrocardiogram is shown below. All of the
following pills were found in the home. Which medication is most likely responsible for this patient’s
symptoms?
a.
b.
c.
d.
e.
Amitriptyline
Esomeprazole
Gabapentin
Gemfibrozil
Hydrocodone
2) A 50-year-old male presents 6 hours after ingesting 20 sustained-release verapamil tablets. He is
asymptomatic and his physical examination is notable for a heart rate of 70 and a blood pressure of
130/85 mmHg. Which of the following strategies for gastrointestinal decontamination is the most
appropriate?
a. Emesis induced by syrup of ipecac, multiple-dose activated charcoal
b. Multiple-dose activated charcoal, whole-bowel irrigation
c. Orogastric lavage, multiple-dose activated charcoal
d. Multiple-dose activated charcoal alone
e. Orogastric lavage, single-dose activated charcoal
3) Which of the following medications is metabolized by plasma cholinesterase and may have enhanced
effects or toxicity in cholinesterase-inhibited patients?
a.
b.
c.
d.
e.
Succinycholine
Atropine
Lidocaine
Meperidine
Diazepam
4) A 30-year-old male presents to the Emergency Department 4 hours after taking 100 tablets of 325mg
Aspirin. The patient is awake and alert. Which of the following physical exam and lab findings is
consistent with this overdose?
a. Pulse 110 bpm, respiratory rate 16/minute, BP 120/78, Pox 98% RA, Temp 98.7 degrees F
Serum pH = 7.32, serum bicarb 18, pCO2 = 50
b. Pulse 110 bpm, respiratory rate 28/minute, BP 120/78, Pox 98% RA, Temp 104 degrees F
Serum pH = 7.45, serum bicarb 10, pCO2 = 28
c. Pulse 45 bpm, respiratory rate 18/minute, BP 96/40, Pox 98% RA, Temp 98.7 degrees F Serum
pH = 7.45, serum bicarb 10, pCO2 = 28
d. Pulse 110 bpm, respiratory rate 28/minute, BP 120/78, Pox 98% RA, Temp 98.7 degrees F
Serum pH = 7.45, serum bicarb 12, pCO2 = 28
e. Pulse 110 bpm, respiratory rate 28/minute, BP 120/78, Pox 98% RA, Temp 98.7 degrees F
Serum pH = 7.40, serum bicarb 18, pCO2 = 40
5) A terrorist group releases a toxic gas inside a subway station. Patients on the scene are described as
having miosis, vomiting, diaphoresis, loss of consciousness and seizures. There are several fatalities at
the scene. Some patients with significant symptoms have been transported to the Emergency
Department by their friends via POV (personally operated vehicle). How should these patients be
decontaminated?
a. Remove the patients’ clothing and wash the patients thoroughly but quickly with soap and
water prior to entering the hospital.
b. Remove the patients’ clothing and wash the patients thoroughly but quickly, and give charcoal
before entering the hospital.
c. No decontamination is necessary since agents that cause these symptoms dissipate rapidly.
d. No decontamination is necessary since agents that cause these symptoms are gases, not
liquids or aerosols.
e. Remove the patients’ clothing and wash the patients thoroughly but quickly with 10% bleach.
6) Which of the following symptoms is not suggestive of a clinically significant tricyclic antidepressant
overdose?
a.
b.
c.
d.
e.
QRS greater than 100 ms
right axis deviation in terminal 40 ms of greater than 120 degrees
seizure
hypertension
Tachycardia
7) The recommended loading dose of insulin for a calcium channel blocker overdose is _____ unit/kg IV.
a.
b.
c.
d.
e.
0.01
0.1
0.25
1
15
8) A 23-year-old ingested 20 amitriptyline 150 mg tablets approximately 30 minutes ago. The ingestion
was witnessed by the patient’s mother. Pt is mildy sedated but follows commands. Her pupils are slightly
large. Vital signs are as follows: BP 136/88, P 110, R 20, Oral Temp 99 F. ECG reveals a PR interval of
200 ms, QRS 88 ms, QTc 355 ms. Appropriate initial therapy for this patient includes:
a.
b.
c.
d.
e.
Immediate intubation followed by activated charcoal 1 mg/kg.
Urinary alkalinization with sodium bicarb drip.
Syrup of ipecac 30cc PO.
Nitroprusside 0.1 mcg/kg/min IV to keep SBP below 110 mmHg.
Propranolol 1mg/min to keep HR below 140 bpm.
9) A 22-year-old male ingested a large overdose of aspirin and several unknown drugs. Upon arrival to
the emergency department he has a GCS of 13 and a respiratory rate of 18 respirations per minute. The
patient is started on a bicarb drip given the history ofan aspirin overdose. Over the next hour his GCS
declines to 7 and his respiratory rate decreases to 10 respirations per minute. He is given a total of 4mg
of naloxone with no response. He is immediately intubated. Shortly after intubation the lab calls to inform
you the patient’s serum salicylate level is 90 mg/dL and his pH is 7.2. Which of the following actions is
the most appropriate?
a. Set the ventilator to a rate of 12 breaths per minute and a tidal volume of 6 mL/kg. Consult
nephrology to dialyze immediately.
b. Set the ventilator to a rate of 22 breaths per minute and a tidal volume of 12 mL/kg. Consult
nephrology to dialyze immediately.
c. Set the ventilator to a rate of 12 breaths per minute and a tidal volume of 6 mL/kg. Recheck a
salicylate level in 1 hour with the plan to consult nephrology if the repeat level is greater
than 100mg/dL.
d. Set the ventilator to a rate of 22 breaths per minute and a tidal volume of 12 mL/kg. Recheck a
salicylate level in 1 hour with the plan to consult nephrology if the repeat level is greater
than 100mg/dL.
e. Set the ventilator to a rate of 22 breaths per minute and a tidal volume of 8 mL/kg. Consult
nephrology to dialyze immediately.
10) The majority of patients with tricyclic antidepressant overdose have symptoms within _____. An
asymptomatic patient with a normal ECG treated with a dose of activated charcoal may be safely
discharged after ____.
a.
b.
c.
d.
e.
12 hours; 12 hours
6 hours; 6 hours
8 hours; 16 hours
6 hours; 12 hours
24 hours; 24 hours
11) What is the most common clinical finding in organic phosphorus poisoning that is not effectively
treated with atropine?
a.
b.
c.
d.
e.
Bronchorrhea
Miosis
Muscle weakness
Diarrhea
Bronchoconstriction
12) Effects of cholinergic excess due to organophosphate exposure include all of the following except:
a.
b.
c.
d.
e.
Nicotinic effects such a tremor, muscle spasm, and muscle weakness
Cardiac effects such a QRS widening and QTc prolongation
Peripheral cholinergic effects such as salivation and lacrimation/sweating
Central cholinergic effects such as mental confusion, delirium, and seizures
Pulmonary effects such as bronchorrhea, bradypnea, and bronchospasm
13) Which of the following medications is most likely to cause ventricular dysrhythmias and seizures in
overdose?
a.
b.
c.
d.
e.
Verapamil
Metoprolol
Diltiazem
Atenolol
Propranolol
14) Which of the following medications is not indicated in the treatment of organophosphate poisoning?
a. Atropine to reverse central and peripheral cholinergic toxicity
b. Benzodiazepines to stop and prevent seizures
c. Pralidoxime to prevent permanent covalent binding of the organophosphate to
acetylcholinesterase
d. Diphenhydramine to reverse central and peripheral cholinergic toxicity
e. Glycopyrrolate to reverse peripheral cholinergic toxicity
15) A 23-year-old male presents to the ED following an overdose of his grandmother’s verapamil. He is
awake, but his vitals are pulse 42 bpm, BP 89/41 mmHg, respiratory rate 18/min, POx 96%o on room air,
temp 98 degrees F. Which of the following therapies should not be started immediately?
a.
b.
c.
d.
e.
IV calcium
IV vasopressors
IV insulin
IV pacemaker
IV normal saline
16) Which of the following is an indication to stop giving repeat doses of atropine in an organophosphate
poisoned patient?
a.
b.
c.
d.
e.
Tachycardia > 145 bpm
Resolution of vomiting and diarrhea
A dose larger than or equal to 20 mg IV
Resolution of pulmonary secretions
Resolution of miosis
17) A 22-year-old woman with a history of depression presents to the ED 4 hours after ingesting 100
tablets of aspirin (325 mg) in a suicide attempt. She denies any other ingestions. Her vital signs are:
blood pressure,110/60 mm Hg; heart rate, 120 bpm; respiratory rate, 22 breaths/min; temperature, 99.1°F
(37.3°C); and pulse oximetry, 98% on room air. On physical examination, the patient is mentating well.
Lungs are clear to auscultation bilaterally, and she is tachycardic with a regular rhythm. Extremities are
warm without edema. Capillary refill is brisk. Laboratory results are: sodium, 145 mEq/L; potassium, 3.6
mEq/L; chloride, 106 mEq/L; carbon dioxide, 21 mEq/L; blood urea nitrogen (BUN), 8 mg/dL; creatinine,
0.9 mg/dL; and glucose, 122 mg/dL. Serum drug screen reveals a salicylate level of 63 mg/dL
(therapeutic range: 10-20 mg/dL) and an acetaminophen level of 7.6 mcg/mL (therapeutic range < 20
mcg/mL). Arterial blood gas testing on room air reveals: pH, 7.41; Pco2, 32 mm Hg; Po2, 103 mm Hg;
base excess, –4 mEq/L; bicarbonate, 20 mEq/L; oxygen saturation, 97%; and lactic acid, 15.3 mg/dL.
What is the most appropriate initial treatment for this patient?
a.
b.
c.
d.
e.
Acetazolamide intravenously (IV)
Hemodialysis
Intubation and hyperventilation
N-acetylcysteine orally
Sodium bicarbonate IV
18) A 22-year-old female presents to the ED after an acute aspirin OD. Her serum ASA level is 80
mg/dL. Her pH = 7.51. The patient is taking deep, rapid breaths with normal mentation. Which of the
following is not indicated?
a.
b.
c.
d.
e.
Activated charcoal PO
2L of NS IV
KCl at 10 meq/hr IV ggt
3 amps of bicarb in a liter of D5W given IV at 200 mL/hr
Endotracheal intubation to prevent respiratory fatigue
19) Tricyclic antidepressant toxicity may be worsened by all of the following except:
a.
b.
c.
d.
e.
Tachycardia
Serum pH 7.55
Extremes of age
Acidosis
Hyponatremia
20) Which of the following is not an indication for hemodialysis is a salicylate poisoned patient?
a.
b.
c.
d.
e.
Level>100mg/dL in acute ingestions
Altered mental status
Urine pH < 6 after bicarb given
Patient unable to handle fluid load due to congestive heart failure or renal insufficiency
Severe acidosis at presentation
21) A 65 yo male with no PMHx except for HTN presents to the ED after taking 50 tablets of his one and
only blood pressure medication. Which of the following lab values indicates to you the overdose was a
calcium channel blocker and not a beta-blocker?
a.
b.
c.
d.
e.
Lactate > 5 mmol/L
Glucose > 200 mg/dL
Potassium > 5 meq/L
Sodium < 140 meq/L
Ionized calcium < 0.9 mmol/L
22) Which of the following symptoms would you least likely see in a 21 yo male after a severe acute
aspirin overdose?
a.
b.
c.
d.
e.
Nausea and vomiting
GI bleed
Seizure
Hyperpnea
Tinnitus
23) A 35 yo female w/ h/o depression presents to the ED 30 minutes after ingesting 60 tablets of 100 mg
amitriptyline. Upon presentations she has mild mydriasis and tachycardia with a heart rate of
109. Otherwise her exam is normal. Which of the following chain of events would you expect with this
patient if no interventions were made.
a. Increased tachycardia, hypotension, seizure, cardiac dysrhythmia, and death over the next 10
hours.
b. Increased tachycardia, hypotension, seizure, cardiac dysrhythmia, and death over the next 2-3
hours.
c. Increased tachycardia, hypotension, cardiac dysrhythmia, seizure and death over the next 2-3
hours.
d. Increased tachycardia, hypotension, cardiac dysrhythmia, seizure and death over the next 10
hours.
e. Bradycardia, hypotension, cardiac dysrhythmia, seizure, and death over the next 10 hours.
24) A 60-year-old male presents to the ED after overdosing on one of his medications. His heart rate is
115 bpm and his blood pressure is 80/40 mmHg. Which of the following medications did he most likely
overdose on?
a.
b.
c.
d.
e.
Propranolol
Verapamil
Labetalol
Diltiazem
Nicardipine