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1. A 19 year old university student presents to the ED via ambulance. She is confused and has a widespread purpuric rash but no meningism. Her temperature is 38.7°C, HR 140 /min, BP 70/30 mmHg.
a. What is the likely diagnosis? (1 mark)
b. List 4 immediate drug management priorities with doses. (4 marks)
Immediate antibiotic administration ceftriaxone 2g IV
IV fluids initial bolus 30ml/kg then further 20ml/kg titrated to response
Noradrenaline if poor response to fluid bolus 10mg in 100mls at 1-20mls/hr aim MAP >65 (or other reasonable dosing schedule)
PPE for staff particularly airway Dr
c. What other management needs to be considered? (2 marks)
Prepare for physiologically difficult intubation
Public health notification and staff plus contact prophylaxis
Treatment of coagulopathy
d. The patient is deteriorating despite aggressive intervention. The parents arrive in the resus room and 5 minutes later the patient has a cardiorespiratory arrest. Outline 3 issues around having the parents present in the resus room. (3 marks)
Many documented benefits for family: reduced PTSD, helps grief, seeing that everything done, felt supported patient, aids family cohesion/bonding. Negatives are can disrupt the resus and need to be removed, needs a dedicated staff member to look after family.
2. A 23 year old man with known asthma is brought to ED by ambulance with an acute exacerbation.
a. What features on history would concern you that his attack might be severe?
Known brittle, ICU admissions, Frequent steroid courses, significant co-morbidities, known poor compliance
b. What features on examination would suggest he had a severe exacerbation?
Altered LOC, reduced RR, accessory muscle use, quiet chest, signs pneumothorax, signs coinfection, cardiovascular compromise
c. Clinical examination confirms he has had a severe episode. List and justify the investigations you would perform.
CXR, coinfection/pneumothorax, ABG evidence of resp failure or hypercarbia
d. List your immediate treatment priorities.
No model answer provided
3. A 25 year old woman presents to ED after a large wooden plank fell on her left foot. She describes pain in the mid-foot region.
a. What are the three components of the Ottawa foot rules (OFR’s)?
Bone tenderness over navicular or base of 5th MT, Ability to weight bear 4 steps at time of injury and at time of the assessment
b. What are the three exclusion criteria for the application of the OFR’s?
Obvious deformity, suspected hindfoot or forefoot #’s
c. Foot x-rays are taken and reveal an isolated un-displaced fracture of tuberosity of the navicular bone. What are 5 important features of your subsequent management?
Analgesia, Plaster POP (walking). Plaster care/check advice, discharge analgesia, follow up ortho clinic
4. A 40 year old male presents with swelling and pain in his right ankle. There is no history of recent trauma.
a. What are 4 major differential diagnoses?
Septic arthritis, Gout, reactive arthritis (Reiter’s), RA, other sero-negative arthritis, drug induced
b. What are 4 important features you would enquire about on history?
Known rheumatologic disorder, previous Gout, recent STI, diarrhoeal or viral illness. Family history, IBD, Systemic symptoms (fever/chills, sweats, lethargy)
c. List and justify 4 investigations you would you order.
FBC; ? anaemia of chronic disease
d. Following full assessment you are confident your patient has an STI. What are your 4 management priorities?
For arthritis analgesia (typically NSAID’s), Inform patient, medical certificate as required.
For STI’s, AB’s doxycycline 100mg 7 days, azithromycin 1G or similar.
Contact tracing, Advice re unprotected sex, Follow up and retesting.
5. A 17 year old woman presented to ED after taking an overdose. She weighs 50kg and has taken 60 tablets of 300mg aspirin.
Her vital signs are:
HR 110 /min
RR 28 /min
BP 100/60 mmHg
Sats 100 % room air
Temp 36.5 °C
a. What features stratify her as high risk? (2 marks)
Dose > 300mg/kg
b. What investigations, apart from an ECG and paracetamol level, would you request? (2 marks)
c. She deteriorates further and requires intubation. What are the specific considerations when intubating patients who have taken an overdose of aspirin? (2 marks)
Avoid acidosis – give Sodium Bicarbonate prior to intubation
Hyperventilate once intubated
Avoid long acting muscle relaxants to monitor for seizure activity
d. What are the indications for haemodialysis? (4 marks)
Unable to maintain urinary alkalinisation
Very high salicylate levels - Acute > 7.2mmol/L, Chronic > 4.4mmol/L
6. A 55 year old woman presents by ambulance. This is her appearance upon arrival in ED:
a. List 3 differential diagnoses.
Angioedema, Anaphylaxis, Trauma (haematoma)
b. List 5 features of her medical history that are particularly important to ask about.
Allergy history, medication history, family history of similar events, previous episodes and how managed
c. State your first 5 management steps.
Resus with full monitoring, Adrenaline neb(5mg) and/or IM (.3-.5mg), urgent airway call (anaesthetics/ICU), difficult airway and surgical airway kit at bedside, optimise current airway by positioning, IV access, supplemental O2 if hypoxia
7. A 35 year old woman presents with palpitations and shortness of breath. On arrival her BP is 70/40 mmHg. An ECG is taken and is shown below.
a. What are 5 important features of the ECG?
Rate @ 240, Rhythm irregular (AF),rightward access, Delta waves, / fusion beats in severalleads esp lead 2 and V1
b. List three possible differential diagnoses.
AF RBBB, WPW with aberrancy, VT, Torsades
c. List the important steps in your immediate management.
Resus with full monitoring, supplemetal O2, iV access, fluid bolus, synchronised DC cardioversion 100J with sedation and analgesia
8. The triage nurse rings you regarding a 32 year old with diabetes and bipolar disorder who is a frequent presenter to your ED. She often presents with disruptive behaviour but the nurse is concerned that today she appears disorientated, ataxic and complains of nausea and vomiting for the last two weeks.
Temp 37.4 °C
HR 110 /min
BP 90/60 mmHg
RR 22 /min
Sats 97 % on air
Her lithium level is 3 mmol/L.
a. List 4 potential causes you would consider in this patient that may have resulted in lithium toxicity.
pre-renal impairment: dehydration
pregnancy with hyperemesis
lithium induced nephrogenic diabetes insipidus
drug interaction with impaired renal excretion - NSAIDs
b. A urine bHCG confirms pregnancy, and a UTI. List four antibiotics used to treat UTI and discuss why you would or would not use them in pregnancy.
nitrofurantoin (avoid after 36/40)
amoxycillin (may be resistant, depends on local sens but safe in preg)
trimethoprim (after the first trimester, folic acid antagonist may increase neural tube defects in first trimester)
cephalexin (broad spectrum but safe in pregnancy)
tetracyclines - tooth discolouration
norfloxacin - renal abnormalities
ciprofloxacin - avoid in pregnancy
c. Your 4th year student asks you about the role of charcoal in lithium overdose. You explain that charcoal does not bind lithium. Name 3 classes of drugs seen in overdose that are not bound by charcoal and give two examples of each.
toxic alcohols - methanol, ethylene glycol, isopropyl glycol, ethanol
heavy metals - iron, lead, potassium, mercury, arsenic, cyanide
d. What alternative enhanced elimination technique may have a role in lithium toxicity?
e. Name 3 toxicokinetic or toxicodynamic features of a drug that make it amenable or appropriate to this method of enhanced elimination, and 2 other drugs toxicities where the method plays a role.
f. You find on questioning that it is likely she is 16/40 pregnant, homeless and with no regular medical care. List and expand briefly on 4 issues that should be discussed with this woman, including other services that may need to be involved.
pregnancy medical care - obstetric physician input given ongoing need for diabetes control and likely lithium requirement during pregnancy - lithium being teratogenic (tricuspid valve abnormalities)
Tie in with GP
psychiatric care and support during pregnancy - tie in with maternal mental health
maternity care, including scans
social supports - social worker involvement
pregnancy advice - safe behaviours/listeria avoidance/drugs in pregnancy/smoking/alcohol
9. A 35 year old woman who is 30 weeks gestation, is brought to your ED after a witnessed cardiac arrest.
a. What are the leading causes of maternal death in pregnancy? (4 marks)
Pulmonary embolism (thrombus)
b. List 5 airway and ventilation issues you could anticipate when attempting to intubate this patient. (5 marks)
Increased risk of aspiration – due to decreased lower oesophageal sphincter tone, increased abdominal pressure, decreased gastric emptying.
More oedematous airways – tongue and supraglottic airways oedematous, and more friable (therefore more likely to bleed and swell) (may need to use smaller ETT)
Decreased FRC and increased O2 consumption – develop hypoxia more quickly, less tolerant of apnoeic periods.
Mask ventilation more difficult due to low FRC, elevated diaphragms, and raised intraabdominal pressure.
Obesity relatively common in pregnancy, causing relative neck extension when supine (causing greater anterior placement of larynx). Also shorter neck in obese gravid women
Large breasts, causing difficult larygoscopy
When ventilating, significant respiratory alkalosis should be avoided as this can cause decreased uterine blood flow.
c. What are the indications for a perimortem caesarean section? (1 mark)
Cardiac arrest in mother, gestational age >24 weeks (age of feus in weeks corresponds to the distance in cm from fundus to symphysis pubis from 18-30 weeks ).
Preferably within 5 minutes of arrest, up to 20 minutes – survival of infant directly related to the time elapsed from maternal arrest to delivery. Poorer neurological outcomes for child if performed > 5mins post arrest.
CPR should continue during and after the procedure.
Consent not required
d. Outline the steps in performing a perimortem c-section.
Make a vertical incision through the abdominal wall from the level of the uterine fundus to the symphysis pubis
If available, use retractors to expose the anterior surface of the uterus and retract the bladder inferiorly
Use a scalpel to make a small vertical incision through the lower uterine segment
Use bandage scissors to extend the incision vertically to the fundus
Deliver the infant, suction the nose and mouth, and clamp and cut the cord
10. You are working in the resus room on a patient who is intubated and has capnography attached.
What are four uses/indications of capnography in intubated patients?
Verification of ET tube placement
Titrating ETCO2 levels in patients (eg in patients with increased ICP)
Determining adequacy of ventilation
Continuous monitoring of tube location during transport
Gauging the effectiveness of resuscitation and prognosis during cardiac arrest
11. A 28 year old man presents to the ED complaining of shortness of breath and pleuritic chest pain. His arterial blood gases are as follows:
a. Give three investigations, other than D-Dimer, you would perform. (3 marks)
F.B.C., CXr, ECG, CRP
b. At this stage give 4 risk factors as described by the BTS to exclude Pulmonary Embolism. (4 marks)
Surgical- major abdo/pelvic surgery, hip/knee replacement, Post op ICU
Obstetric- puerpurium, late pregnancy, Caesarain Section
Lower limb problems- Fracture, Varicose veins
Malignancy- pelvic or abdominal, disseminated
Reduced mobility- hospitalisation, Institutional care
Others- proven previous VTE
His D-Dimer result returns at 0.2 (normal range <0.14)
c. What 2 management steps would you now make? (2 marks)
Start anticoagulants initially LMH- enoxiparin 1.5 mg/kg OD or 1 mg/kg BD
Arrange definitive investigation- spiral CT chest or CT angio or VQ scan if clear CXr, or pulmonary angio
d. The patient becomes acutely short of breath and hypotensive. What management step would you now take? (1 mark)
Thrombolyse with 50 mg bolus of alteplase
12. A 7 year old child presents to the ED with a 12 hour history of headache and photophobia, but no rash.
Urea and Electrolytes as follows
Na+ 125 mmol/L
K+ 3.7 mmol/L
a. Give 2 possible neurological diagnoses for the symptoms described. (2 marks)
Meningitis, intracranial haemorrhage, Migraine, Encephalitis
b. What is the neurological cause for the Hyponatraemia? (1 mark)
c. What are 2 complications of Hyponatraemia? (2 marks)
Seizure, anorexia, headache, drowsiness, nausea and vomiting, tachycardia and about 10 million others
d. List 5 investigations you would perform in the ED for a patient with Hyponatraemia. (5 marks)
Urinalasis, FBC, U&Es, LFTs, BM/glucose, urine osmolality, ECG, CXr, consider CT head, LP if no signs of raised ICP
13. A 45 year old man presents to the ED with a rash on his palm which is intensely itchy. The SHO thinks it is Scabies. A picture is shown below.
a. Describe 2 features of the rash. (2 marks)
Erythematous linear popular rash suggestive of burrows
b. Give the Diagnosis and one differential. (2 marks)
Differential: Insect bites, dermatitis or psoriasis
c. What causes the itching? (1 mark)
Itch caused by reaction to the faeces, eggs and the mites themselves later during disease
d. What are 2 other features of this condition? (2 marks)
Tends to be worse at night and during winter months, tends to affect multiple household members, if undiagnosed lasts for years (7 year itch), can become superinfected
e. What are 2 treatments that could be given to this patient? (2 marks)
Scabicide – e.g permethrin
Antihistamines- tablets or creams
Steroid cream/ointment- 1% hydrocortisone
Crotamiton- anti pruritic topical
f. What further advice would you give to the patient? (1 mark)
Advise thorough hygiene and treatment of all household members
advise to boil wash all clothing and bedding
See GP if not effective or returns
14. A 65 year old man is in your ED with a known overdose of Digoxin. An ECG has been performed and is shown below.
His U+E’s are Na+ 142 mmol/L, K+ 6.7 mmol/L, U50.1, Cr 502.
a. Describe 4 features of the ECG. (4 marks)
Supraventricular bradycardia ? slow AF as no visible p waves, T wave inversion and ST depression inferolaterally, reverse tick sign laterally, prominent u wave laterally,
b. Give 3 indications for digibind. (3 marks)
K+ > 5, digoxin level >15, ingested >10mg, ventricular tachyarrhythmia, haemodynamically unstable bradyarrhythmia, altered mantal status attributable to dig toxicity
c. List 3 other treatments for this patient and give reasons for using them. (3 marks)
Calcium gluconate- 10ml of 10% over 2 min to counteract the hyperkalaemia
Fast acting Insuline 10-15 iu in 500ml of 10% dextrose- increase K+ reabsorbtion
Atropine 0.5 mg up to 3mg to reverse bradycardia
Magnesium in case of torsades de pointes
15. A 30 year old female who works as an accountant and is known to have been depressed for some time is brought to the ED after having been found unresponsive.
An ECG has been taken on arrival and is shown below.
a. Describe the ECG and give the cardiac diagnosis. (2 marks)
Broad complex Tachycardia, regular, most likely Ventricular tachycardia
As you are looking at the ECG the patient has a fit.
b. Given this event, what is the most likely diagnosis for the patient? (1 mark)
c. What drug would you give and what is it’s mode of action? (2 marks)
Drug: Sodium bicarbonate 1mEQ/kg bolus
Mode of action: Unblocks the sodium channels and might reduce the bioavailability of TCAs by increasing their binding to protein
d. What aspects of the patient’s condition would you monitor after giving this drug? (2 marks)
Monitor pulse, BP, rhythm, mental status, oxygenation
e. Give 4 other actions you would take to manage this patients fitting. (4 marks)
Protect airway- recovery position +/- nasopharyngeal airway, give O2 if not already on, IV lorazepam 0.1 mg/kg, call anaesthetist/ICU, follow the seizure pathway
16. A 65 year old male attends complaining of loss of vision in his left eye.
a. Give six features you would enquire about in the history. (3 marks)
Flashers/floaters/ amaurosis fugax
headache/temporal pain/ systemic upset
neurological signs or symptoms
previous medical history e.g. AF, TIA
b. List 2 abnormalities of the fundus shown in the picture above. (2 marks)
Venous engorgement and widespread haemorrhage. Sunset appearance
c. What is the diagnosis? (2 marks)
Central retinal vein occlusion
d. Give 6 associations of this condition. (3 marks)
Trauma- closed head
17. A 10 year old girl has fallen off a wall and presents with a “sore arm”.
X -ray is shown below.
a. Give 3 features which are required to “clear the neck”. (3 marks)
Pt fully conscious
No evidence of intoxication
No neck pain/ midline tenderness
No neurological deficit
No distracting injury
ROM >45o in all directions
Age < 65
b. Describe the x-ray. (1 mark)
Fracture distal shaft of humerus with posterior displacement
c. What is the diagnosis? (1 mark)
Supracondyla fracture humerus
d. What are 2 potential neurological complications of this injury and how would you test for them? (4 marks)
Median nerve palsy- reduced sensation over the palm, reduced thumb opposition and wrist palmar flexion
e. Give an example of one other joint injury that can also give rise to nerve injuries. (1 mark)
Shoulder dislocation- axillary nerve
Neck of fibula fracture- peroneal nerve
Knee dislocation- superficial peroaneal nerve
anterior- femoral nerve
Posterior- sciatic nerve
Medial(acetabular)- gluteal nerves
Wrist- median nerve
18. A 38 year old woman 35 weeks pregnant comes to the ED with visual disturbance and headache. Her BP is 165/100 mmHg.
Hb 8.1 Blood ++ Bil 12
Plt 50 Protein+++ AST 1000
WCC 5.1 Nitrates - GGT 817
a. Describe 2 abnormalities of the FBC and explain them. (2 marks)
Anaemia due to haemolysis
Low platelets due to microangiopathy as part of HELLP syndrome (Haemolysis, elevated liver enzymes and low platelets)
b. What is the likely diagnosis? (2 marks)
Pre eclampsia and HELLP syndrome
c. To control BP what drug, including dose and route, would you use? (3 marks)
Labetalol 10mg IV or 100mg PO
Can use hydralazine 10mg IV
d. Give 3 other steps in the management of this patient. (3 marks)
Call anaesthetist and senior obstetrician.
Magnesium 4-6mg IV
Arrange to deliver baby.
Treat in darkened, quiet room
19. A 28 year old man has been out kite surfing and was thrown into the water at high speed. He is brought in on a spinal board with C-spine protection. He is intubated and ventilated and put on a propofol infusion.
His observations are: Pulse 65 /min, BP 90/60 mmHg and he is warm and well perfused.
The C-spine film and tomogram are shown below.
a. Describe 3 abnormalities on the x-ray. (3 marks)
# body C4, loss of space C3-4, probably soft tissue swelling
b. Describe 2 aspects of his cardiovascular status. (2 marks).
Hypotensive and bradycardic/normocardic
c. What is the likely diagnosis? (2 marks)
d. What 3 signs would support this? (3 marks)
Pink, well perfused peripheries,
flaccid paralysis below level C4,
increased tendon jerk reflexes below that level (might be absent initially)
loss of sensation,
very weak respiratory effort,
20. A 42 year old man has been found outside the ED fitting. He is dishevelled and smells strongly of alcohol.
His BM is 2.4
a. What is the definition of status epilepticus? (1 marks)
Status epilepticus is seizure lasting > 30mins or more than one seizure wiith failure to recover between fits.
b. Name 3 steps in managing his fitting. (2 marks)
Treatments: support airway and give high flow oxygen. And check BM
Give 4mg IV lorazepam or 10mg iv diazemuls.
Pabrinex IV replacement and then give 50mls 50% dextrose or 500mls 10% dextrose IV.
May need phenytoin 18mg/kg IV or thiopentone 4-3-5mg/kg.
c. List 3 reasons for organising an urgent CT head on this man.(3 marks)
Reasons for CT. May have intracranial bleed requiring surgery.
May have meningitis.encephalitis and need LP and look for SOL.
Possibility of closed head trauma
d. Give 4 reasons why alcoholics are more prone to fit. (4 marks)
more likely to have head injury with complications. Alcohol withdrawal.
coagulopathy making bleeds worse,
impaired gluconeogenesis causing low BM
21. A 15 month child comes to the ED following a 3 day history of a viral illness with a maculopapular rash. On the day prior to presentation he had bouts of colic but had been eating and drinking and had been otherwise settled.
He comes to the department unwell, with bloody diarrhoea and a capillary refill time of 3 seconds.
This is his abdominal x-ray.
a. What is the likely diagnosis? (2 marks)
b. List 3 predisposing factors. (3 marks)
Vviral illness, cystic fibrosis, benign or malignant bowel tumours- e.g. putz Jeager, Meckel’s, coagulopathies e.g HSP- causing haematomas, sutures and staples, inverted appendiceal stump, Male gender
c. What are the child’s fluid requirements over the next 12 hours? (3 marks)
Fluids- 1yearold= 10kg, 500 ml over 12 hours, keep UO 2ml/h
d. Name 2 treatment options. (2 marks)
Air contrast/hydrostatic enema if large bowel involved,
22. A 60 year old man comes to the ED with his sister. She says he has been withdrawn and quiet lately, and has been saying he wants to die.
a. Give 6 features in assessing his risk of suicide. (6 marks)
Previous attempt at suicide
Rational thinking loss
No social support
Suicide intent for the future
b. What are 4 important aspects of the mental health act in the state where you work? (2 marks)
No model answer provided
c. How would you ensure this patient could make a decision regarding his treatment? (2 marks)
No model answer provided
23. A man staggers into your department and says that he and many other people have been on a train and were sprayed with a liquid. He then collapses.
a. Other than calling your ED consultant, give 4 actions you would take to manage the situation. (3 marks)
1. Isolate the pt- undress and destroy clothes, thoroughly wash- all done in protective gear
2. inform unit/hospital manager
3. declare major incident standby,
4. contact police to corroborate story
inform ambulance control,
b. Give 4 muscarinic effects of organophosphate poisoning. (4 marks)
c. Give 3 drugs to treat organophosphate poisoning.
Diazepam- 10mg IV, or another benzodiazepine
Atropine- large doses may require 20mg or more infusion
Pralidoxime- specific antidote to organophosphate poisoning
24. A 3 year old girl attends your department late one night. She has stridor but is alert, and has previously been well.
a. Apart from croup, give 4 differential diagnoses. (2 marks)
1. inhaled foreign body
b. List 3 drugs, the dose and route of administration used to treat croup. (3 marks)
1. dexamethasone 0.15-0.6mg/kg,
2. prednisolone 1-2mg/kg,
3. budesonide 1-2mg nebulised,
adrenailne 5mls 1:1000 neb. c. Give 4 aspects of the scoring system to evaluate croup. (4 marks)
3. air entry
d. Give 2 reasons to admit a child with croup. (1 mark)
1. croup score > 2
2. no response to treatment
parental anxiety. late at night as croup tends to get worse overnight.
25. A 35 year old male attends your department. His partner is HIV positive and being treated for TB.
Blood gases on 60% oxygen show:
pCO2 4.0 Kpa (30mmHg)
pO2 16.5 Kpa (124mmHg)
Bicarb 22 mmol/L
Base Excess -1
Chest x-ray is shown below.
a. Describe the chest x-ray. (2 marks)
PA erect CXr- Patchy consolidation in the L upper zone
b. Excluding TB, give 2 differentials diagnoses. (2 marks)
Left upper lobe pneumonia
c. List 3 organisms that may infect the pulmonary system in HIV. (3 marks)
Staphylococcus Aureus, a, Pneumocystis Cariniae, Aspergillous, Streptococcus pneumoniae, Legionell, Haemophylus- you name it it’ll do it
d. Give 6 tests in the ED which would help in the management of this patient. (3 marks)
FBC, U&Es, CRP, Glucose, CD4 count, pulse oximetry, ABGs (sigh), BP
26. A 24 year old male had been assaulted. He has swelling around his LEFT eye and a cut on his RIGHT cheek. Your SHO has requested facial views.
a. Give 3 abnormalities on the x-ray. (3 marks)
left, ? orbital floor fracture. ? fluid level in left antrum.
b. List six aspects of assessment of the orbit and its contents. (4 marks)
Visual acuity. pupil response, anterior chamber/lens and fundus. eye movements, infraorbital nerve function. proptosis and enophthalmos, subcut emphysema.
c. List 3 further steps in this patient’s management. (3 marks)
discus with max fax,
advice re nose blowing.
return immediately if decreased vision or pain on eye movements
Analgesia- eg 800 mg ibuprofen TDS
advice to avoid flying/pressurined areas
commence on ABX
27. A 35 year old man is flown in by air ambulance after being found unconscious in a remote area of bushland in winter. He is in asystole and the ambulance officers are currently performing CPR. His Temp is 28.6°C.
a. What is the current advanced life support algorithm? (3 marks)
Detail in yellow box:
Need Adrenaline doses
b. What are the major modifications needed to be made to this algorithm in the case of unintentional (environmental) hypothermia? (3 marks)
Start and continue ALS until patient is rewarmed (Temp ≥ 32°C) unless other obvious lethal injuries present
Withhold drugs until temp ≥ 30° C then double interval between giving drugs until temp ≥32°C
Can defibrillate initially 3 x if in VF/VT but then cause (as no effect) until temp ≥30°C
Main therapy is re-warming
c. Name 2 methods of each:
Passive external rewarming
Active external rewarming
4 marks (2 each)
Passive external rewarming
Remove wet clothes and dry patient
Active external rewarming
Warmed and humidified air/O2
Warm forced air blanket
Heat packs to torso/armpits/groin
d. Describe 3 methods of active internal rewarming (3 marks; includes at least 1 method of lavage)
b. What 3 underlying injuries could there be? (3 marks)
Facial bone fractures
Base of skull fractures
b. List 5 factors that provide a risk to his airway? (5 marks)
Swollen tongue – haematoma
Direct trauma to airway
ICH causing depressed GCS
Blood loss into airway from facial fractures
29. a. List 4 indications for endotracheal intubation. (4 marks)
To create and airway
To maintain an airway
To protect an airway
To provide for mechanical ventilation
From Cameron, Textbook Adult Emergency Medicine 2009, p 20
b. List 2 indications for non-invasive ventilation. (1 mark)
Acute pulmonary oedema
Respiratory failure (will accept COPD as alternative)
c. List 4 contra-indications to NIV. (2 marks)
Inability to tolerate tight-fitting mask
Lack of trained staff to institute and monitor NIV
d. What is the mechanism of action of NIV? (3 marks)
Controlled FiO2 at set positive pressure –
Recruits alveoli that were closed improving VQ match
Increases pulmonary compliance, decreasing work of breathing
30. A 65 year old male presents following a fall. He complains of a painful swollen left wrist.
An x-ray of his wrist is shown below.
a. Describe his x-ray. (2 marks)
Intra-articular fracture of the distal radius with dorsal angulation
1 mark for intra-articular fracture distal radius
1 mark for dorsal angulation
No marks given for Colles fracture
b. List the contra-indications to performing a Bier's block. (4 marks)
1/2 mark each to maximum of 4 marks from:
Refusal of procedure
Compromised limb circulation
Compartment syndrome of affected limb
Sickle cell disease
Ipsilateral # humerus
LA Sensitivity / allergy
Staff / area / equipment unavailable
Soft tissue injury at tourniquet site
Age <10 / Paediatric patient
Peripheral vascular disease / Raynauds
Severe liver disease
Unable to gain bilateral iv access
Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 9 Page 159 and Cameron Textbook of Adult Emergency Medicine 3rd Edition Chpt 22.2 Pg 701 c. List the key steps in performing a Bier's block. (4 marks)
1/2 mark each for:
Procedures involving stimulation of posterior pharynx
Known airway instability or tracheal abnormality
Thyroid disorder or medication
Risk of raised intraocular or intracranial pressure
Active pulmonary infection or disease including acute asthma and URTI
Full meal within 3 hours (relative contraindication only, balance risk against urgency of procedure)
b. List 4 potential side effects/complications associated with ketamine use in this setting. (2 marks)
1/2 mark each up to 2 marks from the following:
Random movements (can resemble seizure like activity)
Vomiting (during or after procedure)
Failed procedure (need for a General Anaesthesia)
c. Complete the following table regarding ketamine usage in paediatric procedural sedation by route of delivery. (4 marks)
1/2 mark for each correctly completed table cell - only 1 example for advantage / disadvantage by route required for mark - longer list of acceptable answers re: adv/disad examples only in table
1 - 1.5 mg/kg
Nil iv required, as safe as iv
Longer action etc.
More predictable, easier top-up, quicker onset etc.
Pain / distress on injection, less predictable etc.