UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK18–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(16marks)a. Statetwo(2)featuresofa“singletier”traumaactivationsystem.(2marks)

• Activationoffulltraumateam• Activationbasedonphysiologicalparameters,anatomicalabnormalitiesormechanismofinjury

b. Statethemajorlimitationofa“singletier”traumaactivationsystem.(1mark)

• Overactivationwhenmechanismofinjuryalonetriggersactivation-lowspecificity(leadstoinadequateutilisationofresourcesandincreasedworkload)

c. Statetwo(2)featuresofa“twotier”traumaactivationsystem.(2marks)• Gradedresponsewithfulltraumateamactivationonlywithabnormalphysiologicalvariablesorcertain

physicalsignso MaybeprehospitalactivationorattimeofEDassessment

• Activationofsubsetofthefulltraumateamforothercriteria(usuallymechanismofinjuryalone)o eg.GenSxandradiographeralerted,noanaestheticrepresentativerequired

d. Statethetwo(2)majoreffectsofa“twotier”traumaactivationsystemascomparedwithaonetieredsystem.(2

mark)• ↓unnecessary/lowyieldfullteamcallout(espanaesthetics)andthereforebetteruseresources(improve

specificity)• failureoffullactivationwhennecessary-withpotentialdelaysindiagnosisand/ortreatmentpotentiallylife

threateninginjuries

An80yearoldmanisbroughttoyourTertiaryTraumacentreemergencydepartmentafterbeingstruckbyamotorcycleathighspeedwhilewalkingacrossaroad.Hisobservationsonarrivalare:BP105/80mmHgHR105/minRR36/minOxygensaturation85%on15L/minvianonrebreathingmask.GCS15

e. Statethree(3)abnormalitiesshowninthisX-ray.(3marks)

• #Rribs2-8laterally• #in2places-flailsegment• Increasedheterogenouslungopacitiesrightlaterallungconsistentwithpulmonarycontusions• Fracturelateralthirdrightclavicle• Blurringandwideningofuppermediastinum

Thepatientdeterioratesandrequiresrapidsequenceinductionandintubation.YouhaveappropriateIVaccess,butnoothermanagementhasbeenperformedotherthanrapidsequenceintubation.

f. Statesix(6)managementstepsthatyouwouldutilisetooptimisehisventilationpostintubation.(6marks) • R ICC- Insertion right side 28F ICC if USS or CT evidence pneumothorax or haemothorax +/- L sided ICC

dependingonclinicalassessment• NGT-todecompressstomach• Analgesia/Sedation-Ensureadequatee.g.morphinebolus5mgthen5mg/mininfusion,andmidazolam2mg

bolusuntilsedatedthen5mg/hrinfusiontitratedtoresponse• Paralysise.g.vecuronium0.1mg/kgifongoingdifficultywithventilating• Titrateventilator settingsaccording tophysiological response inaccordancewith lungprotectiveventilator

strategiese.g.tidalvolume6ml/kg,PEEP5cmH2increasedasnecessary• Tiltbed/nurseat30°ifnocontraindication

“List”=1-3words“State”=shortstatement/phrase/clause

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Question2(12marks)

a. Listthethree(3)criteriaforacasedefinitionofmeasles.(3marks)• Morbilliformrash• URTIsymptomsincludingconjunctivitisorKoplicsspots• Feverattheonsetoftherash

NB:casedefinitiondoesnotrequireIgMpositivityb. Listfour(4)featuresoftherashseeninassociationwithmeasles.(4marks)

• Feverpresentatonset• Appearsday3-4• Floridconfluenterythematous,maculopauplar,morbilliformrash• Startshead,neck,behindears-spreadstocoverentirebody-includingpalmsandsoles• Heraldclinicalrecovery• Maydesquamate

c. Listfour(4)groupsofpatientsthatarenonsusceptibletomeaslesvirus. (4marks)

• Infants<6/12ifmotherimmune• 1-4yroldswhohavereceived≥1measlesvaccine• 2measlesvaccinations• Born<1966(naturalimmunity)• Documentedevidenceoflaboratoryconfirmedmeasles• MeaslesIgGpresent

Youensureadequateanalgesiaandhydrationforan8montholdwhoappearswellwithacaseofmeaslesinyourdepartment.

d. Listthree(3)otherkeymanagementstepsforthispatient.(3marks)• NotificationtoDHS-REQUIRED• Placeinisolationroom(ideallynegativepressure)• Fullpersonalprotectiveequipmentforstaffe.g.facemask• VitaminA(recommendedforchildren<12monthsbyWHO)• Notificationtohospitalinfectioncontrol• Manageathomeunlesspoororalintake,respiratorycompromiseorCNScomplications• Advicere-excludefromdaycarefor>4/7fromappearanceofrash• Informofpotentialcomplications-OtitisMedia,pneumoniawatchfordrowsiness(Acute

postmeaslesencephalitis)andexplainEDreturncriteriaverbalandwritten• Fullinfectioncleanofroomandleavevacantfor>30min• ContacttracingwithMMR+/-immunoglobulinforsusceptibleindividuals

Themeaslesrash:NB:Noperinasalorperioralsparing.Theeyes/nose/lungs“run”continuously(Brassycough)

Question3(13marks)Itis1000hrsinyourtertiary,mixedemergencydepartment.Youassess12montholdtwinswhopresentwiththreedaysofvomitinganddiarrhoea.Theyhavebothvomited3timesandhad3loosebowelactionstoday.Youdiagnoseviralgastroenteritisforbothtwins.

a. Listthree(3)keyexaminationfindingsthatyouwouldusetoassessthelevelofdehydration.(3marks)• Recentwtchange-Bareweightifweightfromlast2weeksavailable-MANDATORY• Decreasedskinelasticity • CRT>2sec/mottledskin • Absenttears • Abnormalrespiration-e.g.tachypnoea,deepacidoticbreathing • Drymucousmembranes• Sunkeneyes• Tissueturgor• Abnormalradialpulse• Tachycardia(>150) • DecreasedUO

Twin1:.Youestimatefluidlossestobeabout5%bodyweight.Youestimatehisweighttobe10kg.

b. Stateyourapproachtomanagementofthischildforthefirst1hour.(4marks)• AttemptoralrehydrationwithORSat200mls(10-20mls/kg)over1hourinfrequent(5minutely)smallamounts

bycup,icepole,orsyringe,ifnottoleratedduetoflavourdilutejuiceorlemonadeacceptable(althoughlesspreferabletoORS)

• IfongoingGIlossesattemptrapidnasogastricrehydration250mls/hrfor4hoursviaenteralinfusionpump(25ml/kg/hr)

• OndansetronPO2mgstatdoseifongoingsignificantvomitand/orslowrateNGTinfusion(occasionalvomitacceptable)

• Regularantipyreticifongoingfeverleadingtolethargy/apathy• Parenteraleducation-(needtoqualify,notjust“parentaleducation-theQaskedfor“state”)-encouragereturnto

breastfeeding/normalageappropriatedietassoonasable(noneedtoexclude/diluteanyfood/fluids)

c. Justifyyourchoiceforthisregime.Statetwopointsinyouanswer.(2marks)• “Moderate”dehydration-rehydrationviaenteralrouteisaseffectiveastheIVroute• Enteralroutehas:

o fewercomplicationso decreasedadmissionrateso shorterhospitalstayo fasterreturntonormaldietandfluidso improvessymptomsofnauseao morecosteffectivewhencomparedtoIVrehydration

NB:Trytofocusonclinicalefficacy/benefitina“justification”answerratherthan“quick/easy/familiar”etcTwin2:Youestimatefluidlossestobe>15%bodyweightYouestimatehisweighttobe10kg.

d. Stateyourapproachtomanagementofthischildforthefirsthour.Providefour(4)pointsinyouranswer.(4marks)• IV200ml(20ml/kg)bolusnormalsalinerepeatedupto600ml(60ml/kg)intravenous,oruntilshockis

corrected(ifnohepatomegalyorheartdisease)• Measurebloodglucoseandtreathypoglycaemiawith5ml/kgof10%glucose.• Onceshockcorrected,standardintravenousrehydrationwith0.9%normalsaline+5%dextrosedeficit

(1000mls)+maintenance(960mls)at80mls/hrfor24hours(inadditiontoanyfluidbolusesgiventotreatshock)

• CheckUEC,ifK<3add20mmol/LKCl,slowraterehydrationof48hrsifhyperorhyponatraemia

e. Justifyyourchoiceforthisregime.(2marks)Statetwopointsinyouanswer.(2marks)• “shock”bydefinition(>10%weightloss)• Afteradequatecirculatingbloodvolumehasbeenre-established,ongoingrehydrationandmaintenance

fluidsisrequiredwithcorrectionofanyelectrolyteabnormality

Gastroenteritis-FromRCHclinicalpracticeguidelines

ThisguidelinehasbeenadaptedforstatewideusewiththesupportoftheVictorianPaediatricClinicalNetwork

• Infectiousgastroenteritiscausesdiarrhoeawithorwithoutvomiting(non-bilious)orcrampingabdominalpain.• Manycasescanbemanagedeffectivelywithoralrehydration.• Enteralrehydrationispreferabletointravenoushydration.• Shockedchildrenrequireurgentresuscitationwith20mls/kgbolusesofIVNormalSaline.• Childrenonfortifiedformulasneedtohavetheirfortificationceasedduringacuteillness.

Assessment:Isthediagnosisofgastroenteritiscorrect?:Considerimportantdifferentialdiagnoses:

• UTI• Appendicitis• Otherinfections• Surgicalcausesofacuteabdomen

Considerthediagnosiscarefullyifthereis• Abdominalpain• IsolatedVomiting

Aretheresignificantcomorbidities/riskfactors?RedflagsThefollowingfeaturesmayoccuringastroenteritis,butshouldpromptcarefulconsiderationofdifferentialdiagnosesandreviewbyaseniordoctor:

• severeabdominalpainorabdominalsigns• persistentdiarrhoea(>10days)• bloodinstool• veryunwellappearance• bilious(green)vomit• vomitingwithoutdiarrhoea

Childrenwiththefollowingfeaturesshouldbediscussedwithaseniordoctor:

• shortgutsyndrome• ileostomy• complex/cyanoticcongenitalheartdisease• renaltransplantorrenalinsufficiency• veryyoung(<6months)• poorgrowth• useoffortifiedfeeds(concentratedfeedsorcaloricadditives)• recentuseofpotentiallyhypertonicfluids(egLucozade)• otherchronicdisease• repeatedpresentationsforsame/similarsymptoms

DegreeofdehydrationAssessonclinicalsignsanddocumentedrecentlossofweight(NB:Bareweightonsamescalesismostaccurate).Weighbarechildandcomparewithanyrecent(within2weeks)weightrecordings.Precisecalculationofwaterdeficitduetodehydrationusingclinicalsignsisusuallyinaccurate.Thebestmethodreliesonthedifferencebetweenthecurrentbodyweightandtheimmediatepre-morbidweight.Unfortunatelythisisoftennotavailable.Clinicalsignsofdehydrationgiveonlyanapproximationofthedeficit.Patientswithmild(<4%)dehydrationhavenoclinicalsigns.Theymayhaveincreasedthirst.

Moderatedehydration(4-6%) Severedehydration(>/=7%)

• DelayedCRT(CentralCapillaryRefillTime)>2secs• Increasedrespiratoryrate• Milddecreasedtissueturgor

• VerydelayedCRT>3secs,mottledskin• Othersignsofshock(tachycardia,irritableorreducedconsciouslevel,hypotension)• Deep,acidoticbreathing• Decreasedtissueturgor

Other'signsofdehydration'(suchassunkeneyes,lethargy&drymucousmembranes)maybeconsideredintheassessmentofdehydration,althoughtheirsignificancehasnotbeenvalidatedinstudies,andtheyarelessreliablethanthesignslistedabove.Unlessanaccurate&recentlossofweightisavailableasaguide,calculatingpercentageweightlossbyclinicalsignsisonlyanestimation.

DeficitAchild'swaterdeficitinmlscanbecalculatedfollowinganestimationofthedegreeofdehydrationexpressedas%ofbodyweight.(e.g.a10kgchildwhois5%dehydratedhasawaterdeficitof500mls).Thedeficitisreplacedoveratimeperiodthatvariesaccordingtothechild'scondition.Precisecalculations(eg4.5%)arenotnecessary.Therateofrehydrationshouldbeadjustedwithongoingassessmentofthechild.

ReplacementofdeficitReplacementmayberapidinmostcasesofgastroenteritis(bestachievedbyoralornasogastricfluids),butshouldbeslowerindiabeticketoacidosisandmeningitis,andmuchslowerinstatesofhypernatraemia(aimtorehydrateover48hours,theserumsodiumshouldnotfallby>1mmol/litre/hour).

Ongoinglosses(egfromdrains,ileostomy,profusediarrhoea)Thesearebestmeasuredandreplaced-calculationsmaybebasedoneachprevioushour,oreach4hourperioddependingonthesituation.(eg.200mllossoverprevious4hoursbecomesreplacementof50ml/hrforthenext4hours.)

ReplacementofongoinglossesNormal(0.9%)salinemaybesufficient,or5%albuminmaybeusedifsufficientproteinisbeinglosttolowertheserumalbumin.SeeBurnsguidelineforadditionallossesfromburns.

Investigations:Inmostchildrenwithgastroenteritisnoinvestigationsarerequired.Faecalsamplesmaybecollectedforbacterialcultureifthechildhassignificantassociatedabdominalpainorbloodinthefaeces,asabacterialcauseofgastroenteritisismorelikely.However,theseresultsusuallydon'taltertreatment.Extensivetestingforviralandbacterialcausesisexpensiveandusuallydoesnotinfluencetreatment.Someviruses(e.g.enteroviruses)andotherorganisms(e.g.DientamoebafragilisandBlastocystishominis)canbefoundinthestoolsofhealthyindividualsandtheirdetectiondoesnotchangethemanagement.Testingisusuallynotindicated.Considerstoolmicrobiologicalinvestigationsif:•thediarrhoeahasnotimprovedbyday7,particularlyifthechildhasrecentlybeenabroad•yoususpectsepticaemia•thereisbloodand/ormucusinthestool,particularlyifprotractedorthechildissystemicallyunwell•thechildisimmunocompromised.Bloodtests(electrolytes,glucose)arenotnecessaryinsimplegastroenteritisbutarerequiredforchildrenwith:

• severedehydration• renaldiseaseordiureticuse• alteredconsciousstate• 'doughy'skin(suggestinghypernatraemia)• hometherapywithexcessivelyhypertonicfluids(eghomemadesolutionswithaddedsalt)orexcessivelyhypotonicsolutions(egprolongedplainwaterordilutedformula)• profuseorprolongedlosses• ileostomy

Acutemanagement:Ondansetron

• Notrecommendedforchildren<6monthsoldor<8kg• Shouldonlybeadministeredonceinthissetting.

Anti-diarrhoealsarenotrecommended.

Oralrehydration

• Lemonade,homemadeoralrehydrationsolutions(ORS)andsportsdrinksarenotappropriatefluidsforrehydration• Stopanyfeedfortifications(suchasextrascoopsofformulaorPolyjoule)• Encourageparentstofindmethodstohelpchildrendrink.Eg:cup,icypoleorsyringe,aimingforsmallamountsoffluidoften.• Continuebreastfeeding.• SuggestORSeg.GastrolyteTM,HYDRAlyteTM,PedialyteTM• Earlyfeeding(assoonasrehydrated)reducesstooloutput,andaidsgastrointestinaltractrecovery.• Recommendusualdietoncerehydrated.• Ifdiarrhoeaworsensinsettingofformulafeeding,considerthetemporary(2weeks)useoflactosefreeformula.

Trialoforalfluidsintheemergencydepartment:• Mostchildrenwithmild/nodehydrationcanbedischargedwithoutatrialoffluidsafterappropriateadviceandfollow-uparranged.• Aimfor10-20mls/kgfluidover1hourofORS;givefrequentsmallamounts.• SignificantongoingGIlosses(frequentvomitingorprofusediarrhoea)minimisesthechanceofsuccessathome.ConsiderearlyNGTrehydrationinthesechildren.

NasogastricRehydration(NGTR)• Nasogastricrehydrationisasafeandeffectivewayofrehydratingmostchildrenwithmoderatedehydration,evenifthechildisvomiting.ItispreferredovertheIVroute.• MostchildrenstopvomitingafterNGTfluidsarestarted.Ifvomitingcontinues,considerondansetronandslowNGfluidstemporarily.• UseORSeg.GastrolyteTM,HYDRAlyteTM,PedialyteTM.• Thisisnotapplicabletochildrenwithdehydrationfromrespiratoryillnessesegbronchiolitisorwithhypernatremiawhorequireatailoredrehydrationplan[insertlinktobronchiolitis,hypernatremiaguideline]

Rapidnasogastricrehydration:

• 25ml/kg/hrfor4hours• Suitableforthemajorityofpatientswithgastroenteritisandmoderatedehydration(seeindicationsfor'slower'NGRandindicationsforIVrehydrationbelow)• Tocalculatehourlyrateseetable2:

Slowerrehydrationispreferredforthefollowingpatients:

• Infants<6months• Comorbiditiespresent.• Childrenwithsignificantabdominalpain.

Replacedeficitoverfirst6hoursandthengivedailymaintenanceoverthenext18hoursThecalculatedamountsdonotneedtobemodifiedforexactdegreeofdehydrationandshouldbeusedforpatientswithmoderateorseveredehydrationbasedonclinicalsigns.*RCHenteralpumpsdeliveramaximumof300ml/hr;**ieresidualmaintenancedeliveredovershortertimecourse

OngoingprofuselossesduringNGTrehydration:• IfvomitingcontinuesconsiderondansetronandslowNGfluidstemporarily.• Forpatientswhocontinuetohavesignificantvomiting(2largevomitsin1hour)orsignificantabdominalpainduringNGTR,re-examinethepatienttoexcludedifferentialdiagnosesincludingdevelopmentofileus.Ifsatisfiedwithexamination,thenhalverateofNGTfluids.• Ifvomitingcontinuesdespitehalvedrateorprofuseongoingdiarrhoea,consider

• SlowerNGTR• IVfluids

Intravenousrehydration

Indications:

• CurrentevidencesuggestsNGTRissaferandmoreeffectivebutIVrehydrationisindicatedforseveredehydrationandifNGTRfails(eg.ongoingprofuselossesorabdominalpain).• AlsosuitableforchildrenwhoalreadyhaveanIVinsitu.• Certaincomorbidities,particularlyGITconditions(eg.shortgutorpreviousgutsurgery)-discussthesepatientswithseniorstaff.

IVFluidsseeguideline:

• Ifshocked:20ml/kg0.9%sodiumchlodride(normalsaline)boluses,repeateduntilshockiscorrected.If>40ml/kgbolusesrequired,seeshockguideline{link}• Measurebloodglucoseandtreathypoglycaemiawith5ml/kgof10%glucose.• RapidIVRehydration:Inolderchildren>4yearswithmoderatedehydrationwithnocomorbidities,noelectrolytedisturbanceandnosignificantabdominalpain,consider10ml/kg/hr(upto1000ml/hr)for4hoursofPlasma-Lyte148and5%GlucoseOR0.9%sodiumchloride(normalsaline)and5%Glucose,thenreassess.• StandardIVRehydration:Otherwise,rehydrateattheratesinTable4belowforthefirst24hours.• UsePlasma-Lyte148and5%GlucoseOR0.9%sodiumchloride(normalsaline)and5%Glucoseforrehydrationafteranyrequiredboluses.IfserumK<3mmol/L,addKCl20mmol/L,orgiveoralsupplements.• MeasureNa,Kandglucoseattheoutsetandatleast24hourlyfromthenon(morefrequenttestingisindicatedforpatientswithcomorbiditiesorifmoreunwell).Venousbloodgasesproviderapidresults.Itisnotnecessarytosendanelectrolytetubetothelabunlessmeasurementofureaorcreatinineisclinicallyindicated.• Considersepticwork-uporsurgicalconsultinseverelyunwellpatientswithgastroenteritis.

After1st24hours,ifneeded,useStandardIntravenousFluidsunlessabnormalongoinglossesorelectrolytedisturbance.Sodiumabnormalities

• Ifserumsodiumistakenandis<135mmol/lor>145mmol/lseeHypernatremiaguidelineorHyponatremiaguideline.

Monitoringofrehydration

• Bareweighpatient6hourlyinmoderateandseveredehydration,whoarereceivingNGTRorivfluids.• Carefullyreassessafter4-6hours,then8hourlytoguideongoingfluidtherapy.Lookparticularlyfor:

• weightchange• clinicalsignsofdehydration• urineoutput• ongoinglosses• signsoffluidoverload,suchaspuffyfaceandextremities.

DischargeafterRAPIDnasogastricrehydration:Medicalreviewbeforedischargerequiredif:

• <4%wtgain• Signsofdehydrationorotherwiseunwell• ≥3largestoolsduringrehydration• Abdominalpainworsening• AdviceandGastroenteritisFactSheetshouldbegiventoparentsbeforedischarge.EncouragereviewthenextdaywiththeGP.

Considerconsultationwithlocalpaediatricteamwhen:• Riskfactorsidentified• Electrolyteabnormalities• Diagnosisindoubt• Assessedasseveredehydration

Considertransferwhen:• severeelectrolyteabnormalities• severedehydrationorshock

Question4(12marks)A25yearoldmanhasbeenbroughttoyouremergencydepartmentaftersustainingaknifewoundtohisneckinanassault.HisvitalsignsandGCSarenormal.

a. Statefour(4)importantfeaturesoftheinjuryshowninthephoto.(4marks)

• injuryinvolvesall3zonesoftheneck• deepinjurylikelytohavebreachedplatysma• extendsfromanteriormidlinetolateralearlobe,thereforepotentiallyinvolvesallmajor

neckstructures(aerodigestive,vascular,nervoussystem)• largehaematomapresent

b. Listfour(4)deepstructuresthatmaybeinjuredinthispatient.(4marks)

• Airway:Tracheaandlarynx• Vasculare.g.carotidarteryandjugularveins• Neurologicale.g.phrenicnerve(liesonanteriorscalene)orrecurrentpharyngealnerve

(nearthyroid)• Oesophagus

c. Statefour(4)keyfeaturesonhistorythatyouwouldobtain. (4marks)

• detailsweapon/s:number,type,length,edge,sitestabbings• airwayissuese.g.noisebreathing,hoarseness• breathingdifficultiese.g.shortnessofbreath,pleuriticCP• circulationissuese.g.lightheadedness,bloodlost,collapse• neurologicalsymptomse.g.focalweaknessorparasthesia

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These2articleshaveagreatsummaryoftheimportantissues

Question5(12marks)A50yearoldmanpresentsfollowinganepisodeofpalpitationsandsyncope.AtthetimeoftheECGshownheisasymptomatic.

a. Statethree(3)abnormalitiesshowninthisECG.(3marks)• ShortPRinterval<80ms• BroadQRScomplexapprox120mswithdeltawaveconsistentwithWolffParkinsonWhite(type

B)• qwaveII,IIIandaVF,aVRandV1• STsegmentdepressioninlateralleads1mmaVL,V5,V62mmV2-V4• TwaveinversionhighlateralleadsIandaVL

Thepatientexperiencespalpitationsandisnotedtobeinatrialfibrillationonthemonitoratarateof160.Otherthanpalpitations,heisasymptomaticandappearswell.HisBPis150/85.TherearenoothernewchangestohisECG.Therhythmpersists.Heisplacedinaresuscitationcubiclewithfullmonitoringapplied.

b. Statefour(4)stepsinhisongoingmanagementoverthenext20minutes.(4marks)• Attachdefibrillationpadsinanterior-posteriorlocationandturndefibrillationmachineon• Ashaemodynamicallystable-acceptable1stlineoptions:

o flecanide150mgIVover30minutes(appropriateifnormalechoandnoknowncoronaryarterydisease,whilstpreparingforelectricalcardioversion)

OR:o proceduralsedationandelectricalcardioversion

• Ifbecomeshaemodynamicallyunstable-proceduralsedationandelectricalcardioversion• SynchronisedbiphasicDCshock150J,increasedto200Jiffirstshockunsuccessful• OptimiseelectrolytesinparticularpotassiumandmagnesiumaimingK>4.0andMg>1.0mmol

using10mmolKCLorMgSO4over30minutesintravenous• Cardiologyreview-willrequireaperiodofobservationinmonitoredbedasinpatient• Ensurenootherreversiblecasese.g.digoxintoxicity

c. Statethree(3)pointstojustifyyourselectedmanagementapproach.(3marks)

• AFinWPWmayprogresstoVFatanystage• Thereforerhythmcontrol(vsratecontrol)strategyindicated• Currenthaemodynamicstabilitydoesnotreassure• FlecainideistheDOC(instructurallynormalheartwithoutCAD)• IfinformationrestructuralnormalityandpresenceofCADisnotknown→RxofchoiceisDCR

WPW§ Syndromeofsupraventriculartachyarrhythmias→accessorypathway§ 1%ofpopulationPathophysiology:§ Accessoryconnectionsbetweentheatriumandventriclearetheresultofanomalousembryonicdevelopmentof

myocardialtissuebridgingthefibroustissuesthatseparatethe2chambers.§ Althoughdozensoflocationsforbypasstractscanexistinpreexcitation,includingatriofascicular,fasciculoventricular,

intranodal,ornodoventricular,themostcommonbypasstractisanaccessoryatrioventricular(AV)pathwayotherwiseknownasaKentbundle.ThisistheanomalyseeninWPWsyndrome.

§ ConductionthroughaKentbundlecanbeanterograde,retrograde,orboth.ECG§ Deltawaves→depolarisationoffreeventricularwall LOCATION V1 V2 QRSaxisleftposteroseptal(typeA)60% +ve +ve leftrightlateral(typeB) 30% -ve -ve leftleftlateral(typeC) +ve +ve inferior(90degrees)rightposteroseptal 8% -ve -ve leftanteroseptal -ve -ve normal

§ Orthodromic →conductionin95%ofSVTinaccessoryPW(iedownusualPW,thenreenters∴narrowQRS)

∴normalpathwayforventriculardepolarization,accessorytractisusedforreentryECG→deltawaveabsent,QRScomplexisnormal,andPwavesinvertedininf&latleads.

§ Antidromic→5% Lesscommonly,shorterrefractoryperiodintheaccessorytractmaycauseblockofanectopicatrialimpulseinthenormalpathway,withanterogradeconductiondowntheaccessorytractandthenretrogradereentryofthenormalPWQRSiswide,whichisanexaggerationofthedeltawaveduringsinusrhythm(ie,wide-QRStachycardia)

§ Thus,themechanismunderlyingthemajorityofthetachycardiasinpatientswithWPWsyndromeismacroreentrycausedbyanterogradeconductionovertheAVnodeHisbundlepathwayandretrogradeconductionoveranaccessorypathway(orthodromic).LesscommoninpatientswithWPWsyndromeisantidromictachycardia.Evenwhentheaccessorypathwayconductsonlyinretrogradefashion,itcanstillparticipateinthereentrantcircuitandproduceanorthodromicAVreciprocatingtachycardia.

DDx→Lown-Ganong-Levine(LGL)syndrome,patientshaveashortPRintervalandSVT,butnodeltawaveManagement

§ Haemodynamicallyunstable→ DCR→dosecontroversial(ingen.thefibrillationsneed↑↑doses)→M100,B150

Electricalshockdepolarizesallexcitablemyocardium,lengthensrefractoriness,interruptsreentrantcircuits,dischargesfoci,andestablisheselectricalhomogeneitythatterminatesreentry

§ CriticalinWPWisnarrowvswide&regularvsirregularSVTienarrowcomplex,regular-RxasnormalAVNRT(ieSVT)→ vagal,IVadenosine,verapamil(NBAFmayoccur∴ haveDCRready)

§ AF/widecomplextachycardia →chaotic,rapid,QRSmorphologymaybeallovertheplaceAFinWPWis: 1)potentiallyserious2)thedeadliestarrhythmia→normalratelimitingeffectsofAVnodebypassed.→anterogradeconductionviaaccessorypathway∴↑ventricularratesmayleadtoVF

Medicalemergency-needtocardiovertAF→SRURGENTLY:IVFlecainide/DCcardioversionaretheRxofchoiceDigitalisshortensrefractorinessinmyocardiumandbypasstract∴mayaccelerateventricularresponseinAF→lignocainedoesnot↑refractorinessofaccess.tract

OPDMx§ DrugRx

§ ClassIA(eg,procainamide)andclassIC(eg,flecainide,propafenone)blockconductionintheaccessorypathway.§ AmiodaroneandsotalolaffectbothAVnode&bypasstract.Workinsimilarfashionbutblockonlybypasstract.§ ClassIAandICthatprolongtherefractoryperiodinthebypasstractareindicatedifdrugtherapybecomes

necessary.§ ClassICandIAdrugsarebestusedinconjunctionwithanAVnodeblocker,suchasmetoprololorverapamil.§ DigoxinisCIinpatientswithWPWsyndrome.MostdeathsfromWPWsyndromehavebeenassociatedwithdigoxin

§ Electricalablation§ Surgicalablation→Thebestplanistonotusedrugsatall;instead,referallpatientswhohavesymptomaticWPWsyndromeforablationbecausethiscuresthetachycardiaandeliminatesthepotentialdangerouseffectsofdrugs.

Question6(12marks)A47yearoldmanarrivesviaambulancewithlethargy,extremeshortnessofbreathandwheezedespiteIVadrenaline.Hehasapasthistoryofpoorlycontrolledasthmaandmorbidobesity.Youdecidetointubatehimsoonafterarrival.

ReferencerangeFiO2 0.50pH 7.12 (7.35-7.45)pCO2 80 mmHg (35-45)PO2 246 mmHg (80-95)Bicarbonate 18 mmHg (22-28)Baseexcess -14 (-3-+3)O2saturation 99 % (>95)

a. Providetwo(2)calculationstohelpyoutointerprettheseresults. (2marks)

Derivedvalue1:ExpectedCO2:PCO2=1.5xHCO3-+8=33butPCO2is80Derivedvalue2:A-agradientPiO2=(atmosphericpressure -partialpressureofwater) x FiO2 760 -47atsealevel x ~(0.21=RA) PiO2=713x0.5=356 PAO2=(FIO2)(Patm–47mmHg)-(PaCO2)/0.8

PAO2=356-80/0.8=356-100=256∴ A-agradient=PAO2-Pa02=256-246=10whichisnormal∴ suggestsnoshunt,diffusionlimitationorV/Qmismatch

b. Usingthescenarioandthederivedvalues,definethesecondaryacid/baseabnormality/s.(2marks)• Primaryrespiratoryacidosis• Primarymetabolicacidosis

c. Provideaunifyingexplanationforthesegasesinthisclinicalcontext.Statethree(3)points.(3marks)

• Type2respiratoryfailure(hypercapnicrespiratoryfailure)• Probablyacuteonchronicrespiratoryacidosis

o acutelikelyexacerbationofairwaysdisease+/-duetopoorcompliance/precipitant/infectiono chronicsecondaryto?COPD&obesityhypoventilationo potentialthatpatientistiringandhypoventilatingifprolongedprehospitalperiod

• metabolicacidosissecondaryto:o lacticacidosis2˚toadrenaline/salbutamolorpoorperipheralperfusion

• Severeacidosis-likelyacuteonchronicrespiratoryacidosisandmetabolicacidosiso Ifsimplemetabolicacidosisexpect: PCO2=1.5xHCO3-+8=33, butPCO2is80o Ifsimplerespiratoryacidosis,expectHCO3-↑

d. Statethree(3)keyaimsinyoursupportofthispatients’ventilation.(3marks)§ Ensureadequateoxygenation:GivenPaO2on50%→airmixreasonable,↑to100%oxygenationif

deterioration§ Limitpeakpressures:“Auto-PEEP”oftenpresent,avoidPEEP§ allow“permissivehypercarbia”(keyphrase),ifrequired,toavoidhighPIPS(keep<40)§ InspiratorytimetitratedtokeepPIPS<55mmHg§ Avoidgastrapping:LowI:Eratio(ideally<1:3)§ RRtitratedtolowesttolerablepH(eg~10bpm)§ MinimiseVttoavoidalveolardistension(eg.<10ml/kg-carewithestimationsasobese,useleanweight

estimationorestimatedVtwillbetoohigh)• Ensureadequatesedationandmusclerelaxation(paralysetoallowintercostalrelaxationeg.vecuronium)• Volumecycledventilatororhandventilate-NOTtimecycledventilators(havelonginsp/shortexpphases)• Continuousnebulisedsalbutamolmayberequired(highdose-ETT↓aerosoldelivery)• reversetrendelenbergasobese• Considerinhalationanaesthesiaformaintenanceofanaesthesia(bronchodilatorproperties)

Question7(10marks)A75yearoldfemalepresentswithgraduallossofvisioninherlefteye.

a. Whatisthediagnosisforthispatient?(1mark)• Centralretinalveinocclusion

b. Listfive(5)likelyunderlyingcausesforthisdiagnosisinthispatient.(5marks)

• DM• HT• Hyperviscosity• Glaucoma• Atherosclerosis

c. Listfour(4)keypiecesofinformationthatyouwouldprovidethepatient.(4marks)

• Furtherinvestigationsrequired:CT+/-angiographytoassesscirculation• Treatment:

o Nilacuteo SpecialistRx(photocoagulation)aimedatpreventingnewvesselsand2˚glaucomao DiagnosisandRxoftheunderlyingcondition

• Prognosis:o PoordespitebestRx-REQUIREDo Likelymarked↓visioncurrently(potentiallylightperceptiononly),probablywillnot

improveo Othereyeatrisk

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au November2017

Question8(12marks)Youareinaregionalemergencydepartment.Aregistrarapproachesyouforassistancewithoneofhispatients.Thepatientisa30yearoldmanwhopresentedwithaheadache.

a. Statetwo(2)abnormalitiesshowninthisCTscan.(2marks)• Subarachnoidhaemorrhagewithhyperattenuatingmaterial(blood)aroundthecircleofWillis,inter-

hemisphericfissure,andsylvianfissure.• Temporalhornsvisibleraisingpossibilityobstructivehydrocephalus• Lossgrey-whitematterdifferentiationsuggestiveraisedintracranialpressure

b. Listfour(4)featuresonexaminationthatwouldindicateseveredisease.(4marks)

• Stupor,vegetativestate,hemiparesis-Featuressuggestivegrade4or5bleedaccordingtoHuntandHessgradingsystem

• GCS3-6withmotordeficit-Featuressuggestivegrade4or5accordingtoWorldFederationofneurosurgeons• Decerebrateordecorticateposturing• Cushingsresponsewithbradycardiaandhypotension

Hunt&HessBasedonconsciousstate,severityofHA&neurologicaldeficit

GradeI Asymptomatic,minimalHA,mildnuchalrigidityGradeIIMod→severeHA,nuchalrigidity,Noneurol(besidesCNpalsy)GradeIIIDrowsiness,confusion,mildfocaldeficitGradeIVStupor,hemiparesis,vegetativeGradeVDeepcoma,decerebrate,moribundGradeI&II→independent90-95%GradeIV-V→independent10%,dead80%

WorldFederationofNeurosurgeonsbasedonmostimportantfactorstooutcomearelevelofconsciousness&hemiparesis

GradeIGCS15,nomotordeficitGradeIIGCS13-14,nomotordeficitGradeIII GCS13-14,withmotordeficitGradeIV GCS7-12,+/-motordeficitGradeVGCS3-6,+/-motordeficit

Youreviewthepatient.Hereports8/10onpainscoreforheadache.Hehasbeengiven10mgoxycodoneonlypriortoyourreview.Hehas2largeboreIVaccessandfullnoninvasivemonitoringinsituandisinaresuscitationcubicle.Hisobservationsare:BP 220/100mmHgHR90bpmTemperature36.8°COxygensaturation99%onroomairGCS15

c. Listthree(3)keystepsinyourmanagementofthispatientoverthenext30minutes.Stateone(1)pointofdetailforeachmanagementchoice.(6marks)

Managementstep(3marks)

Details(3marks)

Analgesia Morphine5mgbolusthen2.5mgaliquotsintravenoustitratedtosedationlevelandreductionpainscore

Bloodpressurecontrol Labetalol10mgrepeated10minutelyIVtheninfusionat1mg/min,endpointsBP140-160mmHg,inconsultationwithneurosurgeon

MinimisefurtherincreasedinICP

Nurseheadup30degrees Preventsecondaryinjury(hypoxia,hyperthermia,abnormalglucose) Considerhyperosmolartherapye.g.mannitol0.5mg/kgIV Considerprophylacticanticonvulsante.g.levetiracetam500mgIVover15minutesOndansetron8mgintravenousTDS

Dispositionplanning Urgentneurosurgicalreferralthenretrievalserviceforimmediatetransfertotertiarycentre

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Question9(18marks)A2yearoldgirlpresentswithagitation.Shehasbeennotedtohavetakensomeofhergrandmother’stheophyllinetablets.

a. Listthree(3)otherearlyclinicalfeaturesoftheophyllinetoxicity.(3marks)• Vomiting• Tremor• Tachycardia

b. Listthree(3)keyinvestigationsthatarerequiredforthispatient.(3marks)

• Theophllinelevels(serialisbestanswer)• ECG• VBG/ABG

Alsoacceptable:• BSL• Potassiumormagnesium

c. Whatistheroleofdecontaminationinthisoverdose?Statethree(3)pointsinyouranswer.(3

marks)• Oralcharcoalindicated(1g/kg(max50g)POorNGTrecommended)• Evenifdelayedpresentation• Needtoconsiderprotectionofairwayi.e.aggressiveantiemeticsorintubationifco-

existentvomiting

d. Whatistheroleofenhancedeliminationinthisoverdose?Statethree(3)pointsinyouranswer.(3marks)• HDindicatedasthedefinitivelifesavingintervention• Highlyeffectiveifcommencedearly• Commenceassoonaspossiblylifethreateningtoxicityisanticipated

o basedonserumlevels(>500acuteand>330chronic)o clinicalmanifestationofseveretoxicity:arrhythmias,hypotension,seizures

• multidosecharcoalisindicatedinseveretoxicitybutshouldnotdelaymoreeffectiveHD

e. Listthree(3)specificfeaturesofseveretheophyllinetoxicityandlistthespecifictreatmentofeachofthesefeatures.(6marks)

Specificfeature Specifictreatment

1 Hypotension Aggressivefluidswithfluidbolus1000mltitratedtoSBP>90mmHGVasopressorse.g.noradrenaline-1-1mcg/kg/hrintravenous

2 Seizures Diazepam5-10mgIVrepeatedoncePhenobarbitone100-300mgIVassecondlineagent+/-intubation

3 SVT IVBBlockeri.e.metoprolol5mgIVslowpushtitratedSVT(bewarebronchospasminasthmaifpt’sownmeds)

Alsoacceptable

Severehypokalaemia Kreplacement