Saq questions from demt discussion Group: November 2014 Note

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All answers taken from PMH Emergency Department guideline on Ketamine Sedation


32. a. What patient factors may make rapid sequence intubation difficult or impossible? (3 marks)
Upper airway obstruction

Distorted facial or neck anatomy (congenital or acquired)

Poor cervical mobility (acute or chronic)
b. What alternatives should be considered in these cases? (2 marks)
Awake fibre-optic intubation under local anaesthetic

Awake surgical airway (cricothyroidotomy or tracheostomy)


c. List the steps of preparation for rapid sequence induction. (5 marks)
Staff – assemble skilled team, call for expert help if required (anaesthetics/ENT)
Equipment – appropriate size laryngoscope, ETT, syringe, tape, suction, oxygen, airway adjuncts and rescue plan for can’t intubate/can’t ventilate,
Drugs – induction and paralysis agents, pressor, IV fluids with multiple, secure access.
Patient – assess airway and C-spine, fasting status, allergies, medications; pre-oxygenate, optimise position
Monitoring – continuous ECG monitoring, pulse oximetry, BP monitoring and end-tidal CO2 monitor


33. a. Name 2 indications for electrical defibrillation. (2 marks)
VF

Pulseless VT


b. Name 2 areas to avoid placement of pad. (2 marks)
Areas to avoid- ecg electrodes

Medication patches

Breast tissue

Implanted pacemaker/ICD (at least 12-15 cm away)

(any two)

c. Name 4 complications of defibrillation. (4 marks)



  1. Skin burns

  2. Myocardial injury and post defibrillation arrhythmias

  3. Skeletal muscle injury /thoracic vertebral fracture

  4. Electrical injury to the health care provider

d. How will you optimise transthoracic impedance while using a defibrillator for an adult patient? (2 marks)




  1. Use pads 10-13 cm in diameter

  2. Use conductive pads or electrode gels

  3. Perform defibrillation when the chest is deflated(during expiration)

  4. Apply pressure of 5kg for manual defib pads




34.a. Name composition of normal saline and Ringer’s lactate. (2 marks)
Normal Saline – Sodium 154 mmol,CL 154, K+ 0, Ca++ 0

Hartmann’s – Sodium 131mmol, Chloride 111mmol, K+ 5mmol, Ca++ 2 mmol, Lactate 29mmol


b. What are the targets to titrate fluid therapy? (4 marks)
Any 4 from the following –

Physiological – SBP 90, MAP > 65mmHg, HR <100

Perfusion – UOP > 0.5ml/kg/hour, Lactate <2mmol, resolving base deficit, Cap refill < 4s

Invasive measurement – CI >2.5 L/min/m2, PAOP > 15 mmHg.


c. What are the complications of fluid therapy? (4 marks)

Any 4 from the following -

Hypothermia after large volumes of fluid therapy

Coagulopathy due to dilution

Tissue oedema – limb and abdominal compartment syndrome

Pulmonary oedema

Hyperchloraemic acidosis with NS

Anaphylaxis to synthetic colloids /blood transfusion



35. A 60 year old male presents to your ED complaining of chest pain for the last 2 hours. He has no known medication history and does not take any regular medications.
His ECG on arrival is below.


a. What is your interpretation of his ECG? (3 marks)


Inferior STEMI – (1 mark)

Complete heart block – (1 mark)


1 mark for any of:

Possible RV involvement (STE III>II)

Possible posterior involvement (Flat ST depression V2-3)

Bradycardia


b. The patient's blood pressure is 80 mmHg. Outline the key steps in managing his hypotension. (4 marks)
Main priority revascularisation - angioplasty / thrombolysis – (1 mark)

Cautious fluid bolus -must acknowledge risk of pulm odema or use bolus <500ml –(1 mark)


1 mark each for any two of:

Atropine - likely to be ineffective

Avoid / cease GTN

Transcutaneous pacing

Inotropes as listed below only

IABP - only acceptable if preceded by revascularisation


c. The cardiology team have advised you to commence the patient on a vasoactive agent to improve his blood pressure. List 3 appropriate inotropes / vasopressors and their dosing in the table below. (3 marks)





Agent

Dose

1.


Dopamine


3-5 mcg/kg/min to maximum of 20-50 mcg/kg/min

2.

Dobutamine


2-5 mcg/kg/min to maximum of 20 mcg/kg/min

3.

Noradrenaline


2 mcg/min up titrate to response


1/2 mark for each correctly completed box.
Taken from Tintinalli's Emergency Medicine 7th Edition Chapter 54 Table 54-5 Pg 388 with Milrinone excluded.
Consistent with management advice in Dunn Emergency Medicine Manual 5th Edition Vol 1 Chpt 28 Pg 440


36. A 40 year old female is brought to your ED following a 2.5g propranolol overdose taken 3 hours ago.
Vital signs:

Pulse 45 /min

BP 82/45 mmHg

RR 16 /min

Temp 36.8 oC

GCS 13 (E=3, V=4, M=6)

BSL 6.7 mmol/L
a. Outline a step-wise approach to the patient's bradycardia and hypotension? (4 marks)
1 mark each up to 4 marks for each of in a logical order, note HDI may be appropriately commenced very early in the algorithm without penalty

Fluid bolus 10-20 ml/kg

Atropine 100-300mcg iv repeat if response

Isoprenaline infusion

Adrenaline infusion

High Dose Insulin Infusion

Intra-lipid - on toxicology advice only

Pacing - External

Pacing - Transvenous

ECMO

b. Clinical toxicology have been consulted and advised you to commence HDI therapy. How is HDI administered? (4 marks)
1 mark for each of:

Loading dose of glucose 25g (50ml of 50% dextrose) iv bolus

Loading dose of insulin 1IU/kg iv bolus

Infusion of glucose 25g (50ml of 50% dextrose) per hour

Infusion of insulin 0.5IU/kg per hour, may up titrate to effect
c. What are the potential complications associated with HDI therapy? (2 marks)

1 mark for each of:

Hypoglycaemia

Hypokalaemia


Answers taken from Murray et al. Toxicology Handbook 2nd Edition. Section 3.15 Beta-blocker pg 168-170. Section 4.14 Insulin (high-dose) pg398-399.


37. A 72 year old diabetic female is brought to your Emergency Department by ambulance. She complains of feel generally unwell for the last two days with abdominal pain, cough and fevers.
Vitals signs:

Pulse 121 /min

BP 89/58 mmHg

RR 28 /min

Sats 89 % Room Air

Temp 39.8 oC


a. List 3 key steps in this patient’s management. (3 marks)

Resuscitation - 1/2 mark

Screening / diagnosis e.g. blood cultures / biochemistry etc. - 1/2 mark

Antibiotics - broad spectrum cover required - 1 mark

1/2 mark each for any two of:

Source Control

Monitoring

Disposition

Boundary of Care

b. List your resuscitation goals for the first 6 hours. (4 marks)
1 mark each up to 4 marks from:

CVP 8-12 mmHg

MAP >65 mmHg

Urine output >0.5ml/kg/hr

Central venous sats >70% or mixed venous sats >65%

Lactate clearance


c. The patient requires inotropic haemodynamic support. Which inotrope should be used? (1 mark)

Noradrenaline - 1 mark

d. The patient is intubated for respiratory failure. List the four key components of your ventilation strategy for this patient? (2 marks)

1/2 mark for each of :

Tidal volume 6ml/kg

Plateau pressure <30 cm H2O

PEEP Titrated to FiO2 Minimum 5 cm H2O - Maximum 24 cm H20

FiO2 Titrated to Sats 88-95% or PaO2 55-80 mmHg


Answers taken from Surviving Sepsis Campaign International Guideline for Management of Severe Sepsis and Septic Shock 2012 and ARDSnet NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary


38. A 16 year old boy with a congenital heart problem presents to ED with episodes of syncope.
This is his ECG.

a. Describe the ECG. (5 marks)

Paced rhythm rate 75 bpm

Loss of capture

Period of ventricular standstill

Occasional ventricular ectopic/escape beats

P waves rate 75 – 100 bpm, complete heart block
b. Name 5 potential causes for this appearance. (5 marks)
Lead breakage or displacement causing pacemaker failure

Fibrosis causing pacemaker failure

Electrolyte abnormality

Toxicological causes – Ca channel/B blocker/digoxin toxicity

Failure to capture/needs check of threshold for capture
Source: Fellowship VAQ 2013.1


39. A 46 year old man is brought to your ED by ambulance following an overdose of unknown medications. He had a brief generalised seizure en route.
On arrival his observations are:
GCS 12

BP 85/60 mmHg

Temp 37.0 °C

O2 Saturation 100 % on 8 L/min O2


His ECG is shown below.

a. Describe the ECG. (5 marks)




      • Rate 150, Axis normal, Rhythm irregular broad complex tachycardia, R Prime AVR ,

      • Interpretation – consistent with Na Channel Blockade

      • QRS upper limit or slightly prolonged,

      • QT almost half the RR along with examples gave extra marks

b. What are the first 5 things you would do to manage the patient?

Mx in resus area, team approach, delegate care of rest of department

treatment with NaHCo3 (50 ml 8.4%, repeat to achieve pH 7.5 and QRS <120ms)

Fluid Mx for hypotension (1litre 0.9% NaCl stat and repeat if necessary to achieve MAP > 65mmHg)

Benzodiazepines for seizures (appropriate dose for agent chosen)

RSI and ventilation to low normal CO2



40. An elderly man collapses and is unresponsive at a shopping centre.
He receives prompt BLS from bystanders, then defibrillation from an AED prior to the arrival of the ambulance 10 minutes post-arrest. He is found to be in VF and does not revert with defibrillation by the ambulance crew. He is transported to the ED, where he is still pulseless and the monitor shows this rhythm.

What are your immediate actions? (8 marks)
Assume leadership, delegate roles

Ensure continuous BLS provided throughout

Manual biphasic shock 200J

Continue CPR 2 minutes

During CPR:

Check electrode position

Secure IV access

Adrenaline 1mg and repeat after second shock and every second loop

Correct reversible causes (4Hs,4Ts)

Advanced airway

Amiodarone 300mg after 3rd shock

Post-resuscitation care/12-lead ECG/reperfusion


From ARC Resuscitation guideline, online, accessed 5/8/2014


41. A 24 year old woman has just died in your ED despite active resuscitation after sustaining massive head injuries in a motor vehicle accident. Police are in attendance but her family members are unaware of the situation.
a. Provide 6 principles to follow when communicating the news to the family. (6 marks)

Do not tell them over the phone

Say relative is unwell and they need to attend urgently

On arrival, greet in person

Delegate other roles so you will be uninterrupted

Have another staff member present

Introduce yourself and confirm identity and relationship to deceased of all present

Summarise what has happened and state that the patient has died

Do not use euphemisms

Allow whatever form of grief reaction occurs the time and space needed

Ask for and answer questions

Allow viewing of body

Use touch to comfort if appropriate

Offer food and drink

Give access to telephone

Offer pastoral care referral
b. Provide 4 circumstances when a death must be reported to the coroner. (4 marks)
pass/fail - Where there is any suspicion the death is not from natural causes
Additional material (may vary from state to state)

The term “reportable death” means a Western Australian death –

(a) that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury;

(b) that occurs during an anaesthetic;

(c) that occurs as a result of an anaesthetic and is not due to natural causes;

(d) of a person who immediately before death was a person held in care

(e) that appears to have been caused or contributed to while the person was held in care:

that appears to have been caused or contributed to by any action of a member of the Police Force;

(f) of a person whose identity is unknown;

(g) that occurs in Western Australia where the cause of death has not been certified under section 44 of the Births, Deaths and Marriages Registration Act 1998;

(h) that occurred outside Western Australia where the cause of death is not certified to by a person who, under the law in force in that place, is a legally qualified medical practitioner.

42. You are the duty consultant. A 30 year old patient is being brought in by the paramedics as a Priority 1 patient (ETA 5 mins). He was found hanging by his friend at home. Initial rhythm was PEA. The paramedics have been working on the patient for 55 minutes and the patient has not regained circulation. You have been informed that patient is intubated and there is an IO access in.
a. How will you generally prepare for the patient’s arrival? (4 marks)
Likely to be a futile further resuscitation

Gather the team (medical, nursing, scribe)

Prepare ALS drugs and airway equipment

Delegate the floor activities to the next senior

Triage staff to accompany next of kin to relative’s room

Create a resus bed to receive the patient


b. A decision was made to call off the resuscitation attempt immediately after patient arrival. Describe the next steps you will take, (6 marks)
Leave all the lines and tubes in situ

Death to be reported to the coroner

Instruct staff not to handle the body

Leave all evidence including clothing intact

Thorough and complete documentation

Information for next of kin/patient’s GP




43. You are checking pathology results when you come across a positive chlamydia result. The pathologist has flagged that this is a notifiable disease.
a. What action should you take? (5 marks)

Recall the notes

Ascertain whether the patient is aware

Contact the patient and organise for appropriate treatment, advice on barrier precautions, further screening and treatment of sexual partners (may be via GP)

Notify the Communicable Diseases Department for further action/contact tracing

Document all actions in patient notes

b. Give three other examples of incidents that require mandatory reporting in the ED. (5 marks)
May include: Child sexual or physical abuse, elder abuse, incompetent/negligent/substance-abusing/mentally ill (in some jurisdictions) colleague, death during anaesthetic, death in care, death without clear natural cause.


44. You have been asked by the Head of your ED to give a presentation on Access Block and the National Emergency Access Target (NEAT).
a. What is the definition of Access Block? (2 marks)
This refers to the percentage of patients who were admitted or planned for admission but discharged from the emergency department (ED) without reaching an inpatient bed, transferred to another hospital for admission, or died in the ED whose total ED time exceeded 8 hours, during the 6 month time period. Taken from ACEM Policy on Standard Terminology P02v4 March 2009
1 mark for recognising proportion / percentage of patients who do not reaching in-patient bed

1 mark for accurate time frame of exceeding 8 hours


b. What is the National Emergency Access Target? (2 marks)
The National Emergency Access Target requires that by 2015, 90% of all patients presenting to a public hospital Emergency Departments will be admitted, transferred or discharged within four hours – Applies to all of Australia. Taken from WA Government Emergency Access Reform Web Site.

NOTE – New Zealand Access Time Target is 95% within six hours.


1 mark for correct percentage of patients to be admitted.

1 mark for correct time frame of within 4 hours.

c. Outline potential solutions to improving Access Block & Overcrowding (6 marks)

1 mark per entry to maximum of 6 marks- a maximum of 3 marks can be given for Emergency Department specific strategies i.e. for full marks must include minimum of 3 hospital or community based strategies. Table taken from Cameron PA, Joseph AP, McCarthy SM. Access block can be managed. MJA 190;7:364-368. April 2009.




45. a. You are about to see a 4 year old child in ED. Name 3 people considered to have parental responsibility. (3 marks)
A. The child’s parents if married to each other while child being assessed.

  1. Mum or dad if separated as per court order

  2. The child’s legally appointed guardian

  3. DCP

b. Name 3 subsets of ED patients who might not be able to provide consent. (3 marks)


A. Children and adolescents

B. Intellectually impaired

C. Mental health patients

D. Patients under the influence of drug and alcohol

E. Critically unwell patient
c. You are dealing with a hypotensive 6 year old child who was involved in an accident. The patient has free fluid in the abdomen on FAST scan. You need to urgently transfuse the child but the parents are Jehovah Witnesses and are opposing transfusion. Name 2 immediate steps you would take in this situation. (2 marks)
A. Proceed with the transfusion

B. Proper documentation in the notes that blood transfusion is needed to sustain life.


d. What is the legal age of consent in Australia? (1 mark)
18 years and in some circumstances, up to 16 years.

Ref : Textbook of adult emergency medicine by Cameron (3rd edition)



46. a. Name 2 types of consent in the ED. (2 marks)
Implied

Verbal


Written

(any 2)
b. You are going to perform a chest drain on a conscious patient. He is a 60 year old man with a history of COPD who has 50% pneumothorax. His vitals are: Pulse 90 /min, BP 140/80 mmHg, RR 28 /min, Sats 93 % on 2L NP Oxygen. Provide 6 principles you would follow when obtaining consent from your patient. (6 marks)


Ascertain patient is competent

No language barrier

Use simple language/No complicated medical terminology

Treatment options but why insertion of chest drain is needed

Possible complications of chest drain

The consequences of not proceeding with the advised treatment

Opportunity for the patient to ask questions


47. You have been invited to join your Emergency Department’s Quality Improvement Workgroup.
a. List the key steps in the Quality Improvement Cycle. (4 marks)
Plan – the change – 1 mark

Do – implement the change – 1 mark

Check – monitor and review the change – audit – 1 mark

Act – revise / review the plan and repeat the cycle – 1 mark


Exact wording not required statements consistent with concept will be given marks

Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 22 Pg 351

b. List 6 clinical indicators used in Emergency Medicine to measure clinical care and outcomes. (6 marks)

1 mark to maximum of 6 for any of:

ATS Compliance

% Access block

STEMI – time to angio / thrombolysis

Admission rates

DNW Rates

Number of deaths in ED

Time to antibiotics

Time to analgesia

NEAT Compliance

Trauma audits

Satisfaction surveys – patients or staff

Staff retention / sick leave

Patient complaints audit

Notes audits

Occupational health and safety audits – staff injuries or needle sticks etc.

Missed results audit
List not exhaustive – taken from Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 22 Pg 352 and Cameron Textbook of Adult Emergency Medicine 3rd Edition Section 27.3 Pg 822



48. There have been a number of incidents in your ED Short Stay Unit where patients have unexpectedly deteriorated during their stay.
a. Provide 2 examples of the role of a Short Stay Unit. (2 marks)
To manage Emergency Medicine patients who would benefit from extended treatment and observation but have an expected length of stay of less than 24 hours.

Taken from Cameron Textbook of Adult Emergency Medicine 3rd Edition Section 27.2


1 mark for providing extended care for Emergency Medicine patients

1 mark for acknowledging an expected length of stay of 24 hour or less


b. What steps would you take to develop a solution to this problem of patients unexpectedly deteriorating during their stay? (4 marks)

Gather information – 1 mark

Develop solution plan – 1 mark

Implement plan – 1 mark

Audit / Re-collect data – 1 mark

Note exact wording not essential but plan must include aspects of each of these domains to score maximum marks
c. You have been asked to develop a set of exclusion criteria for your Short Stay Unit. List your exclusion criteria. (4 marks)
½ mark for each exclusion criteria to maximum of 4 marks.

Patients who should be admitted to in-patient wards – complex medical or surgical problems

Multiple problems

Elderly patient

Paediatric patients

Patients without clear management plan / diagnosis

Patients with intensive nursing requirements

Risk to staff patients – psychotic, violent, forensic history


Taken from Cameron Textbook of Adult Emergency Medicine 3rd Edition Section 26.6


49. a. Define triage. (3 marks)
Answer must include: a process for sorting patients based on the urgency of need for medical care (3 marks)
b. What are the underlying principles of triage? (2 marks)
Answer must include equity (or justice/fairness) and efficiency (2 marks)
May also mention ongoing process, doing the greatest good for the greatest number, fairness/appropriateness of treat those in greatest need ahead of those who arrived before them.
c. Populate the following table with the correct values. (5 marks)

ATS Category


Max waiting time

ACEM target % seen in time

ATS 1

immediate

100%

ATS 2

10 minutes

80%

ATS 3

30 minutes

75%

ATS 4

60 minutes

70%

ATS 5

120 minutes

70%




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