Saq questions from demt discussion Group: November 2014 Note

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SAQ questions from DEMT Discussion Group: November 2014

Note:


  • X-rays, clinical images and ECGs are reproduced in this document without owner’s consent

  • There are some questions in the document without model answers

  • Items have been briefly reviewed and some typographical errors amended and small changes to increase consistency provided. Detailed quality assurance by the exam sub-committees has not been undertaken.

  • If you have any questions about these items please contact mary.lawson@acem.org.au




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)
Meningococcal Septicaemia
b. List 4 immediate drug management priorities with doses. (4 marks)


    1. Immediate antibiotic administration ceftriaxone 2g IV

    2. IV fluids initial bolus 30ml/kg then further 20ml/kg titrated to response

    3. Noradrenaline if poor response to fluid bolus 10mg in 100mls at 1-20mls/hr aim MAP >65 (or other reasonable dosing schedule)

    4. 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

    • Disposition ICU

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

ESR and CRP; confirm inflammatory process

HLA B27; ?AS

Rheumatoid factor and ANA rule out other

Joint aspirate can diagnose septic arthritis, gout and pseudo-gout

STI tests

Stool tests confirm recent GI infection

NB; x-rays of little value


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

Tachypnoea


b. What investigations, apart from an ECG and paracetamol level, would you request? (2 marks)
ABG

Salicylate level

BSL
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

Serum salicylate levels increasing (> 4.4 mmol/L) despite optimal medical treatment

Altered mental status, acidaemia, renal failure

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

UTI

lithium induced nephrogenic diabetes insipidus



DKA/HHS

drug interaction with impaired renal excretion - NSAIDs

hyponatraemia

acute overdose in the setting of chronic ingestion


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.
Safe

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)
Less optimal

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

acids/alkali

d. What alternative enhanced elimination technique may have a role in lithium toxicity?

haemodialysis
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.
carbemazepine

toxic alcohols

sodium valproate

theophylline

phenobarbitone

salicyclate

potassium
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)

Trauma , (homicide, MVA, suicide )

haemorrhage (placental abruption, placenta previa)

maternal cardiac disease ( AMI, peripartum cardiomyopathy, dysrhythmia )


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.

May benefit maternal outcome also – as it removes the aortocaval compression, and decreases abdominal pressure.

CPR should continue during and after the procedure.

Consent not required
d. Outline the steps in performing a perimortem c-section.


    1. Make a vertical incision through the abdominal wall from the level of the uterine fundus to the symphysis pubis

    2. If available, use retractors to expose the anterior surface of the uterus and retract the bladder inferiorly

    3. Use a scalpel to make a small vertical incision through the lower uterine segment

    4. Use bandage scissors to extend the incision vertically to the fundus

    5. 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:
On Air

pH 7.37


pO2 8.0

pCO2 2.3


BE -2.0
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

U 3.2

Cr 51

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)
Meningitis
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)
Diagnosis: Scabies

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

Calcium chloride- 5 ml of 10% over 2 min

Salbutamol nebuliser 5ml- increases intracellular K+ reabsorption

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)


Tricyclic overdose
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)

Visual acuity

Flashers/floaters/ amaurosis fugax

trauma

headache/temporal pain/ systemic upset



neurological signs or symptoms

eye pain


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

Vasculitis

Hypercoaguability states

Hypertension

DM

Alcohol


Glaucoma


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

Radial nerve – reduced sensation thumb, reduced wrist dorsiflexion

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

Hip dislocation-

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.
FBC WTU LFT

Hb 8.1 Blood ++ Bil 12

Plt 50 Protein+++ AST 1000

WCC 5.1 Nitrates - GGT 817

poikilocytes seen

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

Burst fracture


b. Describe 2 aspects of his cardiovascular status. (2 marks).
Hypotensive and bradycardic/normocardic
c. What is the likely diagnosis? (2 marks)
Spinal shock
d. What 3 signs would support this? (3 marks)
priapism

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)
Intussusception
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,

Surgical



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)
Sex

Age


Depression- H/O

Previous attempt at suicide

Excessive alcohol/drugs

Rational thinking loss

Separated/divorced/widowed

Organised/serious attempt

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)
Diarrhoea

Urination

Miosis

Bronchospasm



Emesis

Lacrimation

Salivation

Piloerection


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

2. epiglotitis

3. angiooedema

4. tracheitis.


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)
1. recession

2. stridor

3. air entry


4. cyanosis
mental state
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:

pH 7.44


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

Aspergilosis

Pneumocystis

Psitticosis

Pneumonitis- viral
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

    • Reversible causes

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:



  1. Passive external rewarming

  2. Active external rewarming

4 marks (2 each)


  1. Passive external rewarming

  • Warm environment

  • Remove wet clothes and dry patient

  • Insulation blankets

  • Warm blankets

  1. 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)




  • Warmed IV fluids (43°C) – 1-1.5°C/hr

  • Lavage

    • Gastric – NGT warmed fluid

    • Bladder – IDC warmed fluid

    • Peritoneal – warmed fluid in/out peritoneal cavity

    • Pleural – warmed fluid in/out of pleural cavity same side; one ICC upper chest, one lower

  • Extracorporeal warming – ECMO 8-12°C/hr




28. A 25 year old man sustains facial injuries in a high speed motor vehicle crash in which he was the unrestrained driver.


His observations are:

GCS 15

HR 100 /min



BP 130/75 mmHg supine

O2 sat 97 % room air

a. Describe 3 abnormalities shown in this photograph. (3 marks)


  • Periorbital bruising bilaterally

  • Facial swelling especially over the right zygoma

  • Haemoserous nasal discharge

  • Possible swollen tongue

  • Chipped right upper incisor

b. What 3 underlying injuries could there be? (3 marks)



  • Facial bone fractures

  • Mandibular fracture

  • Base of skull fractures
  • Intracranial haemorrhage

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

  • Mandibular fracture

  • Small mouth

  • Bull neck




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)


Cameron, p21
c. List 4 contra-indications to NIV. (2 marks)
Coma

Combative patient

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

Uncooperative patient

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

Systolic >200mmHg

Severe liver disease

Unstable epilepsy

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:

1. Consent - ideally written

2. Area / staff / monitoring

3. Bilateral iv access - no marks if only iv access mentioned must specify bilateral

4. Check equipment

5. Inflate cuff - ideally answer should state >100mmHg above systolic

6. Injection of local anaesthetic - prilocaine ideally but accept lignocaine (as per Dunn & Tintinalli)

7.Perform procedure - MUA wrist

8.Deflate cuff / post-procedural monitoring
Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 9 Page 159

31. A 4 year old boy is brought to your ED having sustained a 4cm eyebrow laceration following a fall at a playground. He is accompanied by his mother.

You plan to suture the wound under procedural sedation using ketamine.
a. List 8 contraindications to ketamine use in this setting. (4 marks)
1/2 mark each up to 4 marks from the following:

Parental refusal

Procedural required unsuitable for ketamine sedation

Inadequate staffing / area / equipment

Previous adverse reaction to Ketamine

Altered conscious state

Unstable patient: seizures, vomiting, hypotension

Cardiovascular disease - heart failure, uncontrolled hypertension, congenital heart disease

Procedures involving stimulation of posterior pharynx

Known airway instability or tracheal abnormality

Psychosis

Thyroid disorder or medication

Porphyria

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:

Airway obstruction

Nystagmus

Muscle rigidity

Random movements (can resemble seizure like activity)

Vomiting (during or after procedure)

Emergence phenomena

Apnoea


Failed procedure (need for a General Anaesthesia)

Hypersalivation


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






Intra-muscular (i.m)

Intra-venous (i.v)

Initial dose

4 mg/kg

1 - 1.5 mg/kg

Top-up dose

2 mg/kg

0.5 mg/kg

Advantage

Nil iv required, as safe as iv

Longer action etc.

More predictable, easier top-up, quicker onset etc.

Disadvantage

Pain / distress on injection, less predictable etc.

iv line required, quicker offset etc.




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