Markovchick Vincent J., Pons Peter T., Bakes Katherine M.(ed.) Emergency medicine secrets. 5th ed

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EMERGENCY MEDICINE SECRETS, FIFTH EDITION ISBN: 978-0-323-07167-3

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Notices

Knowledge and best practice in this ﬁeld are constantly changing. As new research and experience broaden

our understanding, changes in research methods, professional practices, or medical treatment may become

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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and

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Library of Congress Cataloging-in-Publication Data

Emergency medicine secrets / [edited by] Vincent J. Markovchick, Peter T.

Pons, Katherine M. Bakes. -- 5th ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-323-07167-3 (pbk. : alk. paper)

1. Emergency medicine--Examinations, questions, etc. I. Markovchick,

Vincent J. II. Pons, Peter T. III. Bakes, Katherine M.

[DNLM: 1. Emergencies--Examination Questions. 2. Emergency

Medicine--Examination Questions. WB 18.2]

RC86.9.M37 2011

616.02’5--dc22

2010040474

Senior Acquisitions Editor: James Merritt

Developmental Editor: Barbara Cicalese

Publishing Services Manager: Anne Altepeter

Senior Project Manager: Cheryl A. Abbott

Design Direction: Steven Stave

3251 Riverport Lane

St. Louis, Missouri 63043

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my wife, Leslie, and daughters, Nicole, Tasha, and Nadia—the four greatest ladies in my world. I

wish to thank them for their lifelong support of all my endeavors and, in particular, for understanding

the time that the editing of this manuscript has taken away from my time with them. I would also like

to acknowledge all the medical students, residents, and attending staff physicians with whom I have

had the pleasure of working at the Denver Health Emergency Department over the past 33 years.

Their enthusiasm and intellectual curiosity have stimulated many of the questions in this book.

VJM

To my wife, Kathy, whose love, support, and remarkable patience make every day worthwhile.

PTP

To Vince, for being a true mentor. To my parents, Phil and Ursula Awad, for believing in me more

than I ever have myself. To my husband and eternal soulmate, Peter, for allowing me the freedom

and support to follow my dreams. And to our children, Sam, Jessie, and Avery, because coming

home to you is my favorite part of the day—I love you…plus one.

KMB

The editors also express their heartfelt thanks to Carol Lucas for her organizational skills, tenacity,

good humor, hard work, and incredible dedication to the preparation of the ﬁfth edition. We could

not have accomplished this without her help.

DEDICATION

Stephen L. Adams, MD, FACP, FACEP

Professor, Medicine and Emergency Medicine;

Chief, Division of Sports Medicine; Chief Emeritus,

Division of Emergency Medicine, Northwestern

University Feinberg School of Medicine; Medical

Director, Emergency Preparedness/Disaster

Services, Northwestern Memorial Hospital; Head

Team Physician, Chicago Cubs National League

Baseball Club, Chicago, Illinois

Manish Amin, DO

Clinical Assistant Professor of Medicine, University

of California, Los Angeles; Associate Faculty,

Department of Emergency Medicine, Kern Medical

Center, Bakersﬁeld, California

Kevin Andruss, MD

Chief Resident, Emergency Medicine, Harbor-

UCLA Medical Center, Torrance, California

Leslie L. Armstrong, MD

Resident Physician, Emergency Medicine, Denver

Health Medical Center, Denver, Colorado

Brandon H. Backlund, MD, FACEP

Assistant Professor, Division of Emergency

Medicine, Department of Surgery, University of

Colorado School of Medicine, Aurora; Attending

Physician, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Katherine M. Bakes, MD

Director, Denver Emergency Center for Children,

Denver Health Medical Center; Assistant Professor,

Emergency Medicine, University of Colorado

Health Sciences Center; Clinical Instructor,

Emergency Medicine, The Children’s Hospital of

Denver, Denver, Colorado

Roger M. Barkin, MD, MPH, FACEP, FAAP

Clinical Professor, Department of Pediatrics,

University of Colorado School of Medicine;

Emergency Physician, Rose Medical Center,

Denver, Colorado

Thomas B. Barry, MD

Clinical Instructor, Emergency Medicine, University

of Rochester; Clinical Instructor, Emergency

Medicine, Strong Memorial Hospital, Rochester,

New York

Sarah M. Battistich, MD

Resident, Emergency Medicine, Harbor-UCLA

Medical Center, Torrance, California

Vikhyat S. Bebarta, MD

Assistant Professor, Surgery (Emergency

Medicine), University of Texas Health Sciences

Center; Chief, Medical Toxicology, Emergency

Medicine, Wilford Hall Medical Center and Brooke

Army Medical Center, San Antonio, Texas

Daniel H. Bessesen, MD

Professor of Medicine, Division of Endocrinology,

Department of Medicine, University of Colorado

School of Medicine; Chief of Endocrinology,

Denver Health Medical Center, Denver, Colorado

Walter L. Bifﬂ, MD, FACS

Associate Professor of Surgery, University of

Colorado School of Medicine; Director of Trauma/

Surgery Outreach and Assistant Director, Patient

Safety and Quality, Denver Health Medical Center,

Denver, Colorado

Diane M. Birnbaumer, MD, FACEP

Professor of Clinical Medicine, Department of

Emergency Medicine, David Geffen School of

Medicine at UCLA, Westwood; Associate Residency

Program Director, Department of Emergency

Medicine, Harbor-UCLA Medical Center, Torrance,

California

CONTRI BUTORS

CONTRIBUTORS v

Joan P. Bothner, MD

Associate Professor, Emergency Medicine, Pediatrics

Department, University of Colorado Denver School of

Medicine; Chief Medical Ofﬁcer, The Children’s

Hospital, Aurora, Colorado

Susan Brion, MD, MS

Chief Resident, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Kerry B. Broderick, MD

Associate Professor of Surgery, Emergency Medicine

Department, University of Colorado School of

Medicine; Attending Physician, Emergency Medicine,

Denver Health Medical Center, Denver, Colorado

Jennie A. Buchanan, MD

Assistant Professor, Emergency Medicine, University

of Colorado School of Medicine; Staff Physician,

Denver Health and Hospital Authority; Attending,

Medical Toxicology, Rocky Mountain Poison and

Drug Center, Denver, Colorado

Joanna M. Burch, MD

Assistant Professor of Dermatology and Pediatrics,

University of Colorado Denver School of Medicine;

Clinic Director of Pediatric Dermatology, The

Children’s Hospital; Staff Dermatologist, University

Hospital, Aurora, Colorado

Valerie N. Byrnside, DDS

Chief Resident, Oral Maxillofacial Surgery, Denver

Health Medical Center, Denver, Colorado

Stephen V. Cantrill, MD

Associate Professor, Emergency Medicine, University

of Colorado Denver School of Medicine, Aurora;

Emergency Physician, Denver Health Medical Center,

Denver, Colorado

Justin C. Chang, MD

Medical Director, Emergency Medicine, Exempla St.

Joseph Hospital; Chief of Emergency Services,

Colorado Permanente Medical Group, Denver,

Colorado

Christopher B. Colwell, MD

Associate Professor, Emergency Medicine, University

of Colorado Denver School of Medicine; Interim

Director, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Catherine B. Custalow, MD, PhD

Associate Professor, Retired, Department of

Emergency Medicine, University of Virginia,

Charlottesville, Virginia

Rita K. Cydulka, MD, MS

Professor and Vice Chair, Emergency Medicine, Case

Western Reserve University; Vice Chair, Emergency

Medicine, MetroHealth Medical Center, Cleveland, Ohio

Daniel F. Danzl, MD

Professor and Chair, Department of Emergency

Medicine, University of Louisville School of

Medicine, Louisville, Kentucky

Christopher Davis, MD

Chief Resident, Department of Emergency Medicine,

Denver Health Medical Center, Denver, Colorado

Erica Douglass, MD

Resident Physician, Department of Emergency

Medicine, Denver Health Medical Center, Denver,

Colorado

Jeffrey Druck, MD

Assistant Professor and Assistant Head of Education,

Department of Emergency Medicine, University of

Colorado Denver School of Medicine, Aurora,

Colorado; Associate Residency Director, Denver

Health Residency Program in Emergency Medicine,

Denver, Colorado

Joshua S. Easter, MD

Physician, Department of Emergency Medicine,

Children’s Hospital of Boston, Boston, Massachusetts

Aaron M. Eberhardt, MD

Instructor, Department of Surgery, Division of

Emergency Medicine, University of Colorado Health

Sciences Center, Aurora; Attending Physician,

Department of Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Jonathan A. Edlow, MD, FACEP

Professor of Medicine, Harvard Medical School; Vice

Chair of Emergency Medicine, Beth Israel Deaconess

Medical Center, Boston, Massachusetts

Catherine Erickson, MD

Physician, Emergency Department, Denver Health

Medical Center, Denver, Colorado

CONTRIBUTORSvi

Scott Felten, MD, FACEP

Assistant Professor, Emergency Medicine,

University of Oklahoma College of Medicine, Tulsa,

Oklahoma

Christopher M.B. Fernandes, MD

Professor, Emergency Medicine, University of

Western Ontario, London, Ontario, Canada

Kelly Flett, MD

Instructor, Pediatrics, University of Colorado School

of Medicine; Pediatrician, Denver Emergency Center

for Children, Denver Health Medical Center, Denver,

Colorado

Joshua B. Gaither, MD

Assistant Professor of Clinical Emergency Medicine,

University of Arizona, Tucson, Arizona

Kathryn Getzewich, MD, MBA, FAAEM

Clinical Assistant Professor, Department of

Emergency Medicine, Temple University,

Philadelphia, Pennsylvania

Shamai A. Grossman, MD, MS

Assistant Professor, Emergency Medicine, Harvard

Medical School; Director, Cardiac Emergency Center

and Clinical Decision Unit, Beth Israel Deaconess

Medical Center, Boston, Massachusetts

Jeffrey S. Guy, MD

Associate Professor of Surgery; Director, Regional

Burn Center; Vanderbilt University School of

Medicine; Nashville, Tennessee

Kent N. Hall, MD

Medical Director, Emergency Department, Goodall

Hospital, Sanford, Maine

Bophal Sarha Hang, MD

Resident, Emergency Medicine, William Beaumont

Hospital, Royal Oak, Michigan

Jason S. Haukoos, MD, MSc

Associate Professor, Emergency Medicine, University

of Colorado School of Medicine, Aurora; Associate

Professor, Department of Epidemiology, Colorado

School of Public Health, Aurora; Director of

Research, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Edward P. Havranek, MD

Professor of Medicine, Cardiology Division,

University of Colorado Denver School of Medicine;

Staff Cardiologist, Department of Medicine, Denver

Health Medical Center, Denver, Colorado

Philip L. Henneman, MD

Professor of Emergency Medicine, Tufts University

School of Medicine, Boston; Attending Physician,

Baystate Medical Center, Springﬁeld, Massachusetts

Robert Hockberger, MD

Professor of Medicine, Division of Emergency

Medicine, David Geffen School of Medicine at UCLA,

Westwood; Chair, Department of Emergency

Medicine, Harbor-UCLA Medical Center, Torrance,

California

John E. Houghland, MD

Resident Physician, Emergency Medicine, Denver

Health Medical Center, Denver, Colorado

Debra Houry, MD, MPH

Vice Chair for Research and Associate Professor,

Emergency Medicine, Emory University School of

Medicine, Atlanta, Georgia

Martin R. Huecker, MD

Resident, Emergency Medicine, University of

Louisville and University of Louisville Hospital,

Louisville, Kentucky

Katherine M. Hurlbut, MD

Clinical Assistant Professor, Surgery, University of

Colorado Health Sciences Center; Attending

Physician, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Timothy R. Hurtado, DO, FACEP

Assistant Professor, Division of Emergency Medicine,

Department of Surgery, University of Colorado

Denver School of Medicine; Attending Physician,

Emergency Medicine, Denver Health Medical Center,

Denver, Colorado

Douglas Ikelheimer, MD, MA

Assistant Professor, Department of Psychiatry,

University of Colorado Denver School of Medicine,

Aurora; Medical Director, Psychiatric Emergency

Service, Department of Behavioral Health, Denver

Health Medical Center, Denver, Colorado

CONTRIBUTORS vii

Michael A. Kohn, MD, MPP

Associate Professor, Epidemiology and Biostatistics,

University of California, San Francisco; Attending

Physician, Emergency Department, Mills-Peninsula

Medical Center, Burlingame, California

Sara M. Krzyzaniak, MD

Resident, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Lela A. Lee, MD

Professor, Dermatology and Medicine, University of

Colorado Denver School of Medicine, Aurora;

Director of Dermatology, Denver Health Medical

Center, Denver, Colorado

Elan S. Levy, MD

Resident, Emergency Medicine, St. Luke’s Roosevelt

Hospital; Resident, Columbia College of Physicians

and Surgeons, New York, New York

Michael M. Liao, MD

Clinical Instructor, Emergency Medicine, University

of Colorado Denver School of Medicine, Aurora;

Research Fellow/Ultrasound Fellow, Emergency

Medicine, Denver Health Medical Center, Denver,

Colorado

Louis J. Ling, MD

Professor and Associate Dean for GME, Emergency

Medicine and Pharmacy, University of Minnesota;

Associate Medical Director for Medical Education,

Hennepin County Medical Center; Senior Associate

Medical Director, Hennepin Regional Poison Center,

Minneapolis, Minnesota

Bo E. Madsen, MD

Instructor of Medicine, Department of Emergency

Medicine, Harvard Medical School; Attending

Physician, Emergency Medicine, Beth Israel Deaconess

Medical Center, Boston, Massachusetts; Program

Director, Icelandic Emergency Medicine Initiative,

Landspitali University Hospital, Reykjavik, Iceland

Mary Nan Mallory, MD

Professor, Emergency Medicine, University of

Louisville School of Medicine, Louisville, Kentucky

Nadia S. Markovchick, MD

Resident, Emergency Medicine, Temple University

Hospital, Philadelphia, Pennsylvania

Kenneth C. Jackimczyk, MD, FACEP

Vice Chair, Department of Emergency Medicine,

Maricopa Medical Center, Phoenix, Arizona; Medical

Director, Eagle Air Medical, Blanding, Utah

Gabrielle A. Jacquet, MD

Resident Physician, Emergency Department, Denver

Health Medical Center, Denver, Colorado

Nicholas J. Jouriles, MD

Professor and Chair, Emergency Medicine,

Northeastern Ohio Universities College of Medicine,

Rootstown; Residency Faculty, Emergency Medicine,

Akron General Medical Center, Akron, Ohio

Juliana Karp, MD

Attending Physician, Department of Emergency

Medicine, Lakeland Regional Medical Center,

Lakeland, Florida

C. Ryan Keay, MD, FACEP

Clinical Instructor of Medicine, Harborview Medical

Center, Seattle, Washington; Clinician, North Sound

Emergency Medicine, Providence Regional Medical

Center, Everett, Washington

John L. Kendall, MD, FACEP

Associate Professor, Emergency Medicine, University

of Colorado School of Medicine; Ultrasound Director,

Emergency Medicine, Denver Health Medical Center,

Denver, Colorado

Andrew M. Kestler, MD, MBA, DTMH

Acting Head, Emergency Medicine, University of

Botswana School of Medicine; Education Director,

Accident and Emergency, Princess Marina Hospital,

Gaborone, Botswana, Africa; Assistant Professor (on

leave of absence), Emergency Medicine, University of

Colorado Denver School of Medicine, Denver, Colorado

Morris S. Kharasch, MD, FACEP

Associate Professor, Emergency Medicine, University of

Chicago Pritzker School of Medicine, Chicago; Director

of Special Programs and Clinical Director, Center for

Simulation Technology and Academic Research,

Division of Emergency Medicine, Northshore University

Health System, Evanston, Illinois

Michael J. Klevens, MD, FAAEM

Director, Emergency Cardiac Services,

St. Luke’s Hospital, Chesterﬁeld, Missouri

CONTRIBUTORSviii

Vincent J. Markovchick, MD, FAAEM,

FACEP

Clinical Professor Emeritus, Emergency Medicine,

University of Colorado Denver School of Medicine;

Attending Staff Physician, Department of Emergency

Medicine, Denver Health Medical Center, Denver,

Colorado

John P. Marshall, MD

Vice Chair, Department of Emergency Medicine,

Maimonides Medical Center, Brooklyn; Assistant

Professor, Department of Emergency Medicine,

Mt. Sinai School of Medicine, New York, New York

Catherine McIlhany, MD, FAAP

Fellow, Child Abuse and Neglect, Department of

Pediatrics, Child Protection Team, The Kempe Center,

University of Colorado Denver School of Medicine;

Fellow, Child Abuse and Neglect, Child Protection

Team, The Children’s Hospital, Aurora, Colorado

Robert M. McNamara, MD, FAAEM

Professor and Chair, Department of Emergency

Medicine, Temple University School of Medicine,

Philadelphia, Pennsylvania

Rick A. McPheeters, DO, FAAEM

Assistant Professor of Medicine, Department of

Emergency Medicine, University of California, Los

Angeles; Chair, Emergency Medicine, Kern Medical

Center, Bakersﬁeld, California

Harvey W. Meislin, MD, FACEP, FAAEM

Professor and Head, Department of Emergency

Medicine, University of Arizona; Service Chief,

Department of Emergency Medicine, University

Medical Center and University Physicians Hospital

(Kino Campus); Director, Arizona Emergency

Medicine Research Center, University of Arizona

Health Sciences Center, Tucson, Arizona

Megan A. Meislin, MD

Resident, Department of Orthopaedic Surgery and

Rehabilitation, Loyola University Chicago, Stritch

School of Medicine, Chicago, Illinois; Resident,

Department of Orthopaedic Surgery and

Rehabilitation, Loyola University Health System,

Maywood, Arizona

Bernadine L. Mellinger, BSN, RN,

SANE-A, CFN

Program Coordinator, Sexual Assault Nurse Examiner

(SANE), Emergency Department, Denver Health

Medical Center, Denver, Colorado

James C. Mitchiner, MD, MPH

Clinical Assistant Professor, Emergency Medicine,

University of Michigan Medical School; Attending

Physician, Department of Emergency Medicine,

St. Joseph Mercy Hospital, Ann Arbor, Michigan

Kendra Moldenhauer, RN, BSN

Director, Patient Safety, Quality and Regulatory

Compliance, Denver Health Medical Center, Denver,

Colorado

Ernest E. Moore, MD

Professor and Vice Chair, Department of Surgery,

University of Colorado Health Sciences Center,

Aurora; Chief, Surgery and Trauma Services, Denver

Health Medical Center, Denver, Colorado

Maria E. Moreira, MD

Assistant Professor, Surgery Department, University

of Colorado Denver School of Medicine, Aurora;

Attending Physician, Emergency Department, Denver

Health Medical Center, Denver, Colorado

Steven J. Morgan, MD

Professor, Department of Orthopaedics, University of

Colorado School of Medicine; Director, Orthopaedic

Trauma, Denver Health Medical Center, Denver,

Colorado

Ashley C. Mull, MS, MD

Instructor/Fellow, Surgery, Division of Emergency

Medicine, University of Colorado School of Medicine;

Clinical Research Fellow, Emergency Medical

Services, Denver Health Medical Center, Denver,

Colorado

Edward Newton, MD

Chair, Department of Emergency Medicine, Keck

School of Medicine; Chair, Department of Emergency

Medicine, Los Angeles County and USC Medical

Center, Los Angeles, California

Björk Ólafsdóttir, MD

House Ofﬁcer, Emergency Department, Landspitali

University Hospital, Reykjavik, Iceland

Ryan D. Paterson, MD

Physician, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

CONTRIBUTORS ix

Jeffrey Sankoff, MD, FACEP, FRCP(C)

Assistant Professor, Emergency Medicine, University

of Colorado Denver School of Medicine; Attending

Physician, Emergency Medicine, Denver Health

Medical Center, Denver, Colorado

Radu V. Saveanu, MD

Chair, Department of Psychiatry, The Ohio State

University; Executive Director, Ohio State University

Harding Hospital, Columbus, Ohio

Jeffrey J. Schaider, MD

Chair, Department of Emergency Medicine, Cook

County Hospital (Stroger), Chicago, Illinois

Kaushal H. Shah, MD

Assistant Residency Director, Emergency Medicine,

St. Luke’s-Roosevelt Hospital; Assistant Professor of

Clinical Medicine, Columbia University College of

Physicians and Surgeons, New York, New York

Barry C. Simon, MD

Professor, Emergency Medicine, University of

California, San Francisco; Chair, Department of

Emergency Medicine, Alameda County Medical

Center, Oakland, California

Corey M. Slovis, MD

Chair and Professor of Emergency Medicine,

Vanderbilt University; Chair, Emergency Medicine,

Vanderbilt University Medical Center; Medical

Director, EMS Bureau, Nashville Fire Department;

Medical Director, Nashville International Airport,

Nashville, Tennessee

Gina Soriya, MD

Clinical Instructor, Department of Emergency

Medicine, Denver Health Medical Center, Denver,

Colorado

Rakesh Talati, MD

Assistant Professor, Emergency Medicine, Tufts

University School of Medicine, Boston; Director,

Medical Simulation, Emergency Medicine, Baystate

Medical Center, Springﬁeld, Massachusetts

Brad Talley, MD

Resident Physician, Emergency Department,

University of Colorado Denver School of Medicine,

Aurora; Resident Physician, Emergency Department,

Denver Health Medical Center, Denver, Colorado

Peter T. Pons, MD, FACEP

Emergency Medicine, Professor, Emergency

Medicine (retired), University of Colorado Denver

School of Medicine, Denver, Colorado; Associate

Medical Director, Prehospital Trauma Life Support,

National Association of EMTs

Peter W. Pryor II, MD, MPH

Assistant Professor, Emergency Medicine, University

of Colorado School of Medicine; Core Faculty,

Emergency Medicine, and Medical Director, Disaster

Medicine, Denver Health Medical Center, Denver,

Colorado

Jedd Roe, MD, MBA, FACEP

Professor, Emergency Medicine, Oakland University

William Beaumont School of Medicine, Rochester;

Chair, Emergency Medicine, William Beaumont

Hospital, Royal Oak, Michigan

Genie E. Roosevelt, MD, MPH

Associate Professor, Pediatrics, University of

Colorado School of Medicine; Attending Physician,

Emergency Department, The Children’s Hospital,

Aurora, Colorado

Carlo L. Rosen, MD

Program Director and Vice Chair for Education,

Emergency Medicine, Beth Israel Deaconess Medical

Center, Harvard Afﬁliated Residency; Assistant

Professor, Harvard Medical School, Boston,

Massachusetts

Peter Rosen, MD

Senior Lecturer in Medicine, Harvard Medical School;

Attending Physician, Emergency Medicine, Beth Israel

Deaconess Medical Center, Boston, Massachusetts;

Clinical Professor, Emergency Medicine, University of

Arizona School of Medicine, Tucson, Arizona

Ethan M. Ross, MD

Resident, Emergency Medicine, Beth Israel

Deaconess Medical Center, Harvard Afﬁliated

Residency, Boston, Massachusetts

Douglas A. Rund, MD

Professor and Chair, Department of Emergency

Medicine, The Ohio State University, Columbus, Ohio

Anthony R. Sanchez II, MD

Assistant Professor, Orthopaedics, University of

Colorado Medical School, Aurora; Chief, Sports

Medicine, Department of Orthopaedics, Denver

Health Medical Center, Denver, Colorado