The following revisions were made to the book as of February 1, 2013 (1st Feedback Revision). All books purchased after this date have these changes incorporated into the book.
Substantial revisions were made in 2017 and the book was re-released as "PEMQBook 2013 Updated." These revisions are not posted here.
1) Page 41. Chapter 6: Cardiology Emergencies. Question and Answer 2. The question was not well worded, and will be revised to the following. The question stem will be changed to: "Which of the following should be administered next?" The answer explanation will be changed as noted in bold and underline font as shown below:
Answer: a. The patient in the vignette has pulseless ventricular tachycardia, and therefore immediate defibrillation is indicated. The ECG tracing shows polymorphic ventricular tachycardia, also known as “Torsade de Pointes.” Characterized by wide QRS complexes with multiple morphologies and changing R–R intervals, it has a number of reversible causes, such as heart block, hypokalemia, hypomagnesemia, drugs, and congenital long QT syndromes. Chloral hydrate is a common sedative hypnotic that is used in the sedation of pediatric patients for dental procedures. In this case, the patient was given 10 times the recommended dose. IV magnesium may have some benefit in patients who fail to respond to defibrillation. Since both Class I (procainamide) and Class III (amiodarone) antiarrhythmics can prolong the QT interval, both would be contraindicated in this patient. [5-Min PEM pp 278-9]
2) Page 52. Chapter 7: Pulmonary Emergencies. Answer 9. The correct answer is D. The rest of the question/answer explanation is correct.
3) Page 77. Chapter 11: Renal and Electrolyte Emergencies. Question 9. Answer choices C and D should be switched (in order of increasing serum osmolality): choice C should be 310 and Choice D should be 315. The rest of the question/answer explanation is correct.
4) Page 115. ID Chapter. Answer 10 explanation. The answer is correct, but the explanation was missing some important elements. The following additions will be changed as noted in bold and underline font as shown below:
Answer: a. This infant has a varicella (VZV) rash or chicken pox, as does the mother. VariZIG is recommended for post-exposure prophylaxis in high-risk individuals, including premature babies (ex-28 weeks) who are hospitalized, immunocompromised children, or for pregnant women. Therefore, this patient should not receive VariZIG. Valacyclovir is not approved in this age group, and therefore acyclovir should be used. Acyclovir has a limited window of opportunity, usually up to 72 hours following the onset of the rash; it attenuates symptoms and transmission only minimally after this time. In neonates who are persistently febrile, secondary bacterial infections with Streptococcus and Staphylococcus species should be considered. Vancomycin and a broad spectrum antibiotic should be given. If the diagnosis is in doubt, a Tzanck preparation may be sent to the laboratory, rather than a tissue biopsy. Aspirin should be avoided for all infants, but particularly for children with varicella, as this has been known to increase the risk of Reye syndrome. [Red Book pp 774-788]
The following revisions were made for the April 15th revision deadline. All books purchased after this date will have these changes incorporated into the book.
5) Page 183. Chapter 27: Trauma: Head and Neck. Answer 25. The answer should be d, and not b. The remainder of the answer explanation is correct.
6) Page 242, Answer 14. The question and answer remain the same, but the answer explanation was improved. The last sentence (end of paragraph) should be changed to:
The vaccine schedule for IM administration is the same for both of these vaccines and has recently been shortened to only 4 doses: days 0, 3, 7 and 14. For immunosuppressed patients, 5 doses of the vaccine on days 0, 3, 7, 14, and 28 should still be given. [Tintinalli pp 1052-6; Rupprecht 2010]
7) Page 72, Question 14, option "d" should be changed to: "Calcium gluconate 100 mg/kg IV over 5-10 minutes”
8) Page 304, Question 72: Changes are in bold and underline font. Option "d" in the Question stem should be replaced with: “Epinephrine 0.01 ml/kg, 1:1,000 IM." Likewise, the answer explanation for Question 72 (page 324), should be changed to: “(or 0.01 ml/kg of a 1 mg/mL or 1:1000 dilution, max dose 0.5 mL).”
9) Page 233 and 235. Question and Answer 18 were removed. The question and answer needed revision, but as this was a controversial, evolving topic, we opted to remove it instead.
10) Page 260. Chapter 38, Answer 2: The answer explanation had minor clarifications, as noted in bold font below:
Answer: a. The picture demonstrates retinal hemorrhages, which have been reported in as many as 85% of surviving victims of abusive head injuries and in 100% of fatalities. Retinal hemorrhages from abuse are unique in that they can be unilateral or bilateral, present in all 3 layers of the retina, extend out to the periphery, and are described as too numerous to count. They may be present with or without extra-axial hemorrhages or other injuries. They may present as the only manifestation of abuse. The remaining answers are incorrect. Retinal hemorrhages cannot be dated. In the majority of cases they do not result in permanent vision loss. Retinal hemorrhages from birth are usually few in number but may be numerous, and are localized to the posterior pole or the intraretinal layer. The majority resolve by 10 days, and almost all by 6 weeks. Retinal hemorrhages associated with increased intracranial pressure are also few in number and located at the posterior pole. An ophthalmology consult is indicated within the first 24 hours of presentation, but can be delayed if the child’s neurological status is tenuous. It should not be delayed more than 72 hours.Cardiopulmonary resuscitation is not associated with retinal hemorrhages. Pertussis and SIDS are likewise not associated with retinal hemorrhages.[CAN pp 35-9, 402-13; Watts 2013]
11) Page 261-2. Chapter 38, Answer 12: The answer choice is correct, but the answer explanation was reworded substantially. The answer explanation should now read:
Answer: a. In the evaluation of possible sexual abuse in children, the emergency physician should consider risk factors for sexual abuse separate from those for child abuse and neglect (question #9). Children at risk are those who have a history of sexual abuse, have low self-esteem, are impulsive, come from single parent homes, have multiple caretakers, or have family members who were victims of abuse or incest. Females are more often victims than males. Physically disabled and/or developmentally delayed children are at high risk for sexual because they are often less independent and cannot communicate the abuse to others. Children are at increased risk if their parents have a history of mental illness, domestic violence or drug or alcohol abuse. The remaining answers are not risk factors for sexual abuse. [CAN pp 16-23]
PEMQBook 2013 has been finalized, and no further changes will be made to the print version. The following revisions will be incorporated into the Challenger Online Version of PEMQBook 2013 only, but are listed here for your reference:
12) Page 73 and 75. Chapter 10, Question and Answer 19: Answer choice "a" should be changed to "Decreased calcidiol (25-hydroxy vitamin D) level" and the correct answer should be changed to "b" instead.
13) Page 164. Chapter 25, Question and Answer 3: There were arguably 2 correct answers for this vignette, and therefore, the question and answer should be changed as follows:
A 5 yo male presents to the ED with left lower leg pain after being run over by a car. He is unable to walk and is complaining of significant pain, swelling, and tingling of the lower leg. On palpation, the posterior aspect of his left lower leg is hard, swollen, and tense. He has a decreased left posterior tibialis pulse. The most appropriate immediate treatment for his condition is:
a. Application of a long leg splint
b. Fasciotomy
c. Application of traction
d. Elevation and icing of the leg
e. NSAIDS and bed rest
Answer: b. This patient has compartment syndrome as a result of a tibia/fibular fracture from trauma. He has paresthesias, pain, and decreased pulses. Pallor and paralysis tend to be late findings. Compartmental pressures should be measured to confirm the diagnosis, and are likely to exceed 30 mmHg. Orthopedics should be consulted to perform a fasciotomy to prevent muscle necrosis and/or nerve palsies. The other choices would not be appropriate and/or adequate treatment of compartment syndrome. [F&L pp 1583-4]
14) Page 246, Chapter 37, Question 15: Answer choice "d" should be changed to:
d. Treat with esmolol 0.025-0.1 mg/kg/min infusion
In other words, the "mcg" should be changed to "mg"
The following updates were made after PEMQBook 2013 was updated in 2017, and apply to this updated version of P2013U. The Updated P2013 incorporated all edits listed above, and in some cases, question/answer sets were deleted for P2013U.
1) Page 20, Chapter 3: Neonatal Resuscitation and Newborn Problems: Question 23. IVF recommendations have changed. This question should be deleted.
2) Page 42, Chapter 6: Medical Emergencies: Cardiology: Question 7. The clinical vignette wasn’t written clearly to exclude endotracheal intubation as the correct answer, so there are 2 correct answers. However, the teaching points in the answer explanation are still valid.
3) Page 97, Chapter 14: Medical Emergencies: Rheumatology: Question 5. There is a correction in the answer explanation that is relevant for general teaching. C3 and C4 levels are decreased in SLE, not increased, and we have edited the answer explanation to clarify this point.
...Anti-Double-Stranded DNA antibodies will be elevated and help you confirm the diagnosis of SLE. C3 and C4 complement levels will be decreased in SLE. The CBC will not help your diagnosis…
4) Page 182, Chapter 27: Trauma: Head, Face, and Neck: Question 15. The answer is correct, but a clarification on the PECARN criteria was added to the answer explanation as follows:
By PECARN head injury rules, any LOC in children older than 2 years, including LOC> 5seconds, is an indication to consider brain CT after closed head injury….
5) Page 220, Chapter 33: Procedures: Question 14. The answer is correct, but the injection should be just lateral (radial) to the palmaris longus tendon. This question vignette wasn't written perfectly, and answer option d should have been "1 cm medial (ulnar)..." and therefore, this is confusing. However, "1 cm" is incorrect in this case, so answer b is still the best answer, and the teaching points are still valid, especially with this correction, as noted below.
...1% lidocaine is injected with a 25 gauge or smaller needle 1 cm proximal to the flexor crease of the wrist just lateral (radial) to the palmaris longus tendon…
6) Page 244, Chapter 37: Toxicology: Question 9. Codeine is now black box listed, and therefore, there are now 2 correct answers to this question. The teaching points are otherwise mostly valid (minus the codeine teaching point).