UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK14–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)A45yearmanpresentsfollowingacollapse.Hisobservationsare:BP130/70mmHgTemp36°O2saturation98%onroomair

a. Statefour(4)abnormalfindingsshowninthisECG.(4marks)• Sinustachycardia100bpm• STE:

o 4mminV1-2,“Downsloping”or“Coved”o Brugadasign(asthisisfollowedbyinvertedTwave)

• STD2mmV4-V6,II,III,aVF• TWV1-2,aVL,biphasicinV3

b. WhatisthesignificanceofthisECGforthispatient?Listtwo(2)pointsofsignificance.(2marks)

• InassociationwithsyncopeisdiagnosticofBrugadasyndrome• Needsadmissiontomonitoredbedtomonitorformalignantarrhythmia• HighuntreatedmortalityfromVF(~10%/year)

Type1(CovedSTsegmentelevation>2mmin>1ofV1-V3followedbyanegativeTwave)istheonlyECGabnormalitythatispotentiallydiagnostic.TheothertwotypesofBrugadaarenon-diagnosticbutpossiblywarrantfurtherinvestigation.Type2has>2mmofsaddlebackshapedSTelevation.Brugadatype3canbethemorphologyofeithertype1ortype2,butwith<2mmofSTsegmentelevation.c. Whatisthepathophysiologicalbasisforthisproblem?(3marks)

• Mutationinasodiumchannelgene(sodiumchannelopathy)• Eitherspontaneousorfamilialclustering(autosomaldominant)• Subendocardialfibrosisorreplacementofmyocardiumwithadipose

d. Listfour(4)likelyprecipitatingcausesforthispresentation.(4marks)NB:ECGchangesofBrugadasyndromecanbetransientandcanbeaugmentedorunmaskedbymultiplefactors

• Drugs:o NaChannelblockers/CCB/BBlockerso Nitrateso Cholinergicstimulationo Alcoholo Cocaine

• Fever• Myocardialischaemia• ↓K+ • PostDCR• Alcohol• Hypothermia

e. Listfour(4)otherclinicalfeatures(Clinicalfeatures=Hx&Ex)thatmayalsobeassociatedwiththisproblem.(4marks)

NB:TobeDxas“BrugadaSyndrome”: 1)BrugadasignonECG(CovedST>2mmin>1ofV1-V3followedbyTWI)& 2)Oneofthefollowingclinicalcriteria(orsyncopeashere)• VF• PolymorphicVT• FHxsuddencardiacdeath<25yearsold• Coved-typeECGSinfamilymembers• InducibleVTwithflecainideorelectricalstimulation• Nocturnalagonalrespiration

f. Whatisthespecifictreatmentofchoiceforthisproblem?

• AICD (orQuinidineifAICDCIegneonate)

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

Question2(12marks)A45yearoldmanisbroughtintoyouremergencydepartment,byambulance,withisolatedseverepaininhisrighthipafterafallfromhismotorbikeonehourearlier.HehasapasthistoryofIVDU.TheambulanceofficerswereunabletoobtainIVaccessandhaveprovidedpenthraneforanalgesiaalone.Hisambulancehandoverobservationsare:BP95/50mmHgHR130bpmRR24bpmOxygensaturations98%RAGCS15Hisprimarysurvey,includingaFASTscan,isnegative.Youarrangeatraumaseriesplainxray.

a. Statefive(5)stepsinyourinitialapproachtoprovisionofanalgesia.Includeanydrugdosesandroutes.(5marks) NB:HxIVDU

• Continuepenthrane/redosepenthraneifonlysingledosegiven• Inhalational:Nitrousoxide50/50• INfentanyl-anticipate>usualdosesneeded(usual1.5mcg/kgacceptto2mcg/kgrepeatsamedose

in10/60ifinadequate)• IMketamineafterHxtaken:2-3mg/kg,followedbyKetamine10-20mgIVwhenIVaccessobtained• IVnarcotic-morphinewhenIVaccessobtained-anticipatehighlevelsneeded-15-20mgtotal+.May

aggravatehypotension.Fentanyl25-50mcgtitratedabetteroption.

b. Statefive(5)abnormalfindingsshowninthisxray.(5marks)

• Comminuted # of R femur at junction of prox and mid 1/3 with 100% off ending andangulation.

• DislocatedRhip,likelyanteriorwithinfero-medialdisplacement• Transverse#Rpubicbone,symphysisnotwidened• #Rsuperiorpubicramus/acetabularfloorwithmedialdisplacement• metalandmaterialartifactRthigh

Hisinjuriesareconfirmedtobeisolatedtothoseshowninthehipxrayonly.Despiteyourinitialprovisionofanalgesia,hecontinuestocomplainofseverepain.

c. Statetwo(2)pointsinyouron-goingapproachtohisanalgesia.Includeanydrugdosesandroutes.(2marks)• Reduced#femurandlongitudinaltraction• FurtherIVketamine-10mgbolus/backgroundinfusion• FemoralnerveblockunderUSguidance(0.5%2-3mg/kg)

NB:givenHxIVDU-PCAisrelativelyCI

Question3(12marks)

a. Completethetabletodistinguishbetweentheinvestigativefeaturesofdiabeticketoacidosisandhyperosmolarnonketoticstate.(4marks)

Investigation Diabeticketoacidosis Hyperosmolarnonketoticstate

BSL

>11(rarely>30) BSLveryhigh(>33)

Osmo

N Hyperosmo>350mosm/L

Acidosis pH<7.3HCO3<15

Mildorabsent(mayhavemildLacticacidosis

Seketones ≥0.6mmol/L(usually>10mmol/L)

≤0.6

Ur:Cr

increased

b. Completethetabletodistinguishbetweenthemanagementofdiabeticketoacidosisand

hyperosmolarnonketoticstate.(8marks)

KeyManagementstep Diabeticketoacidosis Hyperosmolarnonketoticstate

Fluidrequirements ~5Ldeficitreplacedover24-48/24 Greatervolumesneeded-8-20L,slowIVreplacementover48-72/24

Insulinrate Requiredat0.1IU/kg/hrifBGL>15 Maynotberequired.Ifrequired,lowerdose0.05IU/kg/hr

K+replacement Initialrate10-20mmol/hrOftenlargedeficit

Deficitsvariable

VTEprophylaxis Notusu.clinicallyrelevant VTEmajorcauseofmorbidity/mortality

Rxunderlyingcause

Question4(12marks)

A65yearoldwomanpresentswithasevereheadache.Sheisotherwiseasymptomaticandtakesnoregularmedications.Herobservationsare:

BP 245/130mmHgHR 80 bpmRespiratoryrate 18 bpmTemperature 36 °COxygensaturation 100% roomairGCS 15

a. Listfour(4)keyexaminationfindingstoseekonyourexamination.Listwhyeachsignisimportant.(4marks)

Examinationfinding Whyisthissignimportant?

Papilloedema

↑ICP

Meningism-neckstiffness

↑ICP-SAH

CNIII

Suggestsaneurysm

Renalabruit

RAS

Renalmass

RCC

Adrenalmass

Cushingsyndromefeatures

LeadstopossibleunderlyingDx

Hypertensiveretinopathy EndorganeffectoflongstandingHT

LVF,4thheartsound

CCF

b. Listfour(4)drugoptionsforthemanagementofherbloodpressure.Foreachstateyourinitialdoseandroute.(8

marks)

Drugoption Dose/routeLabetolol(stroke,preeclampsia+withGTNindissection)

10-20mgIVbolusrepeatedevery10minuntiltargetBPobtainedthen1-2mg/mininfusion

Hydralazine 5-10mgbolusrepeated10minutely

GTN(ischaemia,LVF) 300-600mcgS/LFollowedbyinfusion5mcg/kg/hrtitratedtoresponse

Phentolamine(Phaeo) 1-5mgbolusestomaximum15mg

Nifedipine 60mgQIDPO

Morphine 2.5mgboluses5/60

Question5(12marks)

A6weekoldfemaleinfantpresentswithvomiting.a. Listsix(6)likelycausesofvomitinginthispatient.Statetheclinicalfeaturesthatwouldallowyoutodifferentiateeach

cause.(12marks)Causeofvomiting Distinguishingclinicalfeature/s

Overfeeding

Hx of overfeeding + absence of features of other seriouscause

Reflux

smallmilkpossetspostfeedsinwellinfant

Sepsis

Temperature,

Pyloricstenosis projectilenonbiliousvomitingpostfeeds,thenhungry,oliveshapedmass,visibleperistalsisR-L

Intussusception Intermittentepisodescryingandpallor,wellinbetween

Malrotation Distended abdo, distressed with pain, bilious vomiting,feedingissuessincebirth

NEC Prematurity

Metabolicdisorder FHxsame,FFT,↓BSL(98%have≥1episodeofhypo)DysmorphicSeizures

Infectivegastro rapid onsetdiarrhoea+/- vomiting, fever, abdominal pain,oftenhistorycontactwithanotherpersonwithsimilarSx

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Question6(12marks)

A23yearoldmanpresentedwithapainfulneckafterdivingintoapool.

a. Statethree(3)abnormalfindingsshowninhisx-ray.(3marks)

• #antC5-flexionteardrop• Anteriordisplacementoffracturefragment• Disruptionmiddlecolumn• STswellinganteriorly

b. Isthisinjurylikelytobestableorunstableandwhy?(2marks)

Stableorunstable Why?

Unstable • Ligamentousdisruptionhighlylikely-anteriorlongitudinal

• 2columnsinvolved-anterior&middlec. Listfour(4)physicalmethodsthatyoucouldutilisetoimmobilisethispatient.(4marks)

• RigidCxspinecollar• Sandbagsandtape• Foamhardblockandspinalboard• Strappinghead,thorax,abdo,pelvis• Vacuummattress

d. Ifthepatientistoremainnotintubated,listthree(3)othernon-physicalmeasurescouldyouemploytoensurespinalimmobility• Explaintoptandensureheisawaretoliestill• Analgesia• Antiemetic• Sedation

Question7(10marks)

An87yearoldmanfromanursinghomepresentsfollowingageneralisedseizure.

Hisobservationsare:BP120/70mmHgHR100bpmTemperature36.8°COxygensaturation97%roomairGCS12E4,V3,M5

a. Providetwo(2)calculationstohelpyoutointerprettheseresults.(2marks) • Derivedvalue1:Serumosmo2xNa+Ur+glucose=396• Derivedvalue2:Aniongap =185-25-137=21• Ur:Crratio>100

b. Whatisthelikelycauseforthisclinicalpicture?(2marks)

• Dehydrationsecondarytoswallowingdisability/institutionalisation/infection/illness/drugs

c. Completethefollowingtabledemonstratingthree(3)keyspecifictreatmenttasksandstatehowyouwouldachieveeachofthese.(6marks)

Keytreatmenttask Howwillyouachievethetask?

Replace fluid/ reduceNa

Waterdeficit=0.6xpremorbidweightx(serumNa-140)/(140)Replace water deficit with 5% dextrose over 24-48hrs aiming for fall inNaconc0.5mmol/hr0r<10-15mmol/24hrs,checkNaregularlytomonitorprogressandadjustRx+willneedmaintenanceandongoinglosses

Treatunderlyingcauseinfectionetc

Asguidedbyhxandex+/-moreIxEg.If central diabetesinsipidis, ADH supplementation, desmopressin 1-2mcgIV/dayonceeuvoaelmic

DiscussionwithfamilyregoalsRxandceilingsoftreatment

highmorbidityandmortalityexpectedPreexistingadvancecaredirections,premorbidQOL

This resource is produced for the use of University Hospital, Geelong Emergency staff for preparation for the Emergency Medicine Fellowship written exam. All care has been taken to ensure accurate and up to date content. Please contact me with any suggestions, concerns or questions. Dr Tom Reade (Staff Specialist, University Hospital, Geelong Emergency Department) Email: tomre@barwonhealth.org.au November 2017

Question8(12marks)

A4yearoldgirlpresentswithapainfulrighteyeforthelast1day.

a. Usingthetableprovided,listsix(6)clinicalfeaturesthatwoulddifferentiatebetweeninsectbite,

preseptalandorbitalcellulitis.(6marks)Clinicalfeature Insectbite Preseptalcellulitis Orbitalcellulitis

Source Bitewitnessed,visible

N N

Systemicfeatures(unwell,febrile,nauseated)

N Possible Verylikely

Opthalmoplegia/↓eyemovements

- - Present

Proptosis - - Possible(latesign)

Presenceofanteriorchanges-chemosis

- - Possible

↓VA N N Possible

RPAD - - Possible

b. Assumingthediagnosisisorbitalcellulitis, listthree(3)keymanagementpointsforthispatient.

Provideonejustificationforeachchoice.(6marks) Keymanagementpoint Justification

IVantibiotics-IVfluclox+ceftriaxone

InfectionwithseriouscomplicationsnecessitatingparenteralAbsCoverStaph,Strep,HInf

Analgesia Verypainfulcondition

Admit/disposition UrgentOpthalmologyconsultasmayrequireorbitaldecompressionifCTprovenabscess

Question9(18marks)a. Completethetable,listingsix(6)causesofneonataljaundice.Listeachcauseinthecharacteristictimeframefor

appearanceofjaundice.(4marks)Timetoonsetofjaundice Causeofneonataljaundice

<2days

• ABOincompatibility• Rhincompatibility• Bacterialsepsis• TORCHinfections• HaemolysisegG6PDdeficiency

2-3days • Physiological

3-7days• Bacterialsepsis• Toxoplasmosis• CMV

>1week

• Bacterialsepsis• Hepatitis• Congenitalbileductatresia• Congenitalhaemolyticanaemia• DruginducedHaemolyticanaemia• Rubella• Herpes• Hypothyroidism• Breastmilkjaundice

b. Listtwo(2)biochemicalfeaturesseenwithpathologicaljaundice.(2marks)• Conjugatedbilirubin• SeBili>13

c. Listthree(3)optionsforthemanagementofpathologicaljaundice.(3marks)

• Observe• Phototherapy• Exchangetransfusion

d. Define“ApparentLifeThreateningEvent”.(1mark)

• Anepisodethatisfrighteningtotheobserver,characterisedbysomecombinationof:o Apnoeao Colourchangeo Changeinmuscletoneo Chockingorgagging

e. Listthree(3)featuresofabenign“ApparentLifeThreateningEvent”.(3marks)

• Termchild• Previouslywell• Symptomstemporallyrelatedtofeeding

f. Listfive(5)investigationsthatareindicatedinapatientwhoshowsfeaturesofaserious“ApparentLifeThreatening

Event”.• FBE&diff• U+E• RBG• NPAforviruses/pertussis• ECG(espforQT)

Consideredinselectedcases:lactate,ammonia,acycamitineprofile,EEG,CTB,Holter,toxscreen,metabolicscreen

FromRCH:

ALTEDefinitionAnepisodethatisfrighteningtotheobserverandischaracterizedbysomecombinationof:

• Apnoea(centralorobstructive)• colourchange(cyanotic,pallid,orplethoric)• changeinmuscletone(usuallydiminishedbutmaybestiffening)• chokingorgagging

Insomecases,theobserverfearsthattheinfantwilldieorhasdied.Notes"ApparentLifeThreateningEvent(ALTE)"isnotadiagnosisbutratheradescriptionwhichencompassesabroadrangeofpresentationsdescribedinthedefinitionabove.Whileausefultermforclinicianstocollectivelydescribethesepresentations,itisatermwhichcanprovokeunnecessaryanxietyandalarminparents.Inwellover95%ofpatientswiththesepresentationsthecauseisphysiologicalorarelativelybenignpathologicalcondition(seebelow).Theterminologyshouldnotbeusedinfrontofparentsoronwrittenmaterialstheymightseewithoutcarefulthoughtandexplanation.ALTEisapresentationofinfancy,withhighestfrequencyinthefirst3monthsoflife.Approximately0.1%ofotherwise-healthytermbabieswillpresenttoanemergencydepartmentwithanALTE.ThereisnoprovenassociationbetweeninfantswithALTEpresentationsandSuddenInfantDeathSyndrome.Theepidemiologyisdifferent,andthereisnodocumentedincreasedriskofsubsequentSIDSinotherwisewellterminfantswhopresentwithanALTE.Theterm'near-missSIDS'shouldnotbeused.Whilethereisalonglistofpotentialcausesofsuchpresentations,extensiveinvestigationhasaverylowyieldandisunwarrantedinmostcases.Targetedtestingismoreappropriate.HistoryHistoryshouldbetaken,ideallyfirst-hand,frompersonswhoobservedtheinfantduringorimmediatelyaftertheevent.1.Descriptionofevent:

• Whatalertedthecaregivertoaproblem?• Behaviouralstate:awakeorasleep• Colourandcolourdistribution(cyanosis,pallor,plethora)• Tone-stiff,floppyornormal• Seizure-likeactivityorabnormalmovements,includingabnormaleyemovements

2.Circumstancesandenvironmentpriortoevent:• Relationshipoftheeventtofeedingandhistoryofvomiting• Sleepposition-prone/supine/side• Environment:natureandtypeofsleepingarrangement,chair,lounge,crib,carseat,bedaswelltype

ofbeddingandclothing3.RecentIllnessandFamilyHistory:

• Historyofcoryzaorotherupperorlowerrespiratorytractsymptomsininfantandfamilymembers• Relevantpastmedicalhistory(especiallyprematurity),immunisation• Socialfactorsincludingdrugsandmedicationtakenbycaregiverorgiventoinfant

4.Interventionsusedbycaregivers• Degreeofresuscitationrequired:gentle/vigorousstimulation,mouth-to-mouth/CPR

ExaminationAdetailedgeneralphysicalexaminationisrequired,bearinginmindthepossiblecauses.Payparticularattentionto:

• Neurologicalstateandfontanelle• Cardiorespiratoryexamination• Examineentireskinofbabyforevidenceofinjury• ConsiderfundoscopicexaminationifNAIsuspectedandconsultseniormedicalstaff(possible

ophthalmologyreview)• Abdomenformass,andinguinoscrotalabnormalities

Risk-assessmentThefollowingcriteriasuggestahigherriskofanunderlyingcauseormoreproblematiccourse:

• Agelessthan28days• Significantprematurity• Significantpriormedicalillness• Clinicallyunwelllooking.• Recurrenteventsbeforepresentation• Moresevere/prolongedALTEsymptoms

PossibleCausesItiscommonfornospecificdiagnosistobemadeafterevaluationandaperiodofobservation.Exaggeratedphysiologicalairwayprotectionreflexesisthemostcommonexplanation(readmore)OccasionallytheALTEisthefirstsignofadevelopingviralrespiratoryinfection,withmoretypicalcoryzalillnessorbronchiolitisappearinginsubsequentdays.Muchlesscommon,butpotentiallymoreseriouscausesinclude:

• Childabuse(shakenbaby,drugoverdose,Munchausenbyproxysyndromeorintentionalsuffocation)• Infection:Pertussis,pneumonia,meningitis,septicaemia• Airwayobstruction:congenitalabnormalities,infection,hypotonia• Abdominal:intussusception,strangulatedhernia,testiculartorsion• Metabolicproblems:hypoglycaemia,hypocalcaemia,hypokalaemia,otherinbornerrorsof

metabolism• Cardiacdisease:congenitalheartdisease,arrhythmias,vascularring,prolongedQT• Toxin/Drugs:accidentalornon-accidental• Neurologicalcauses:headinjury,seizures,infections,cerebralmalformationsetc.

InvestigationsInapreviously-wellterminfantwithaclearhistoryofALTEsymptomstemporallyrelatedtofeeding,thediagnosticyieldofinvestigationsisverylow.Investigationsforthisgroupareoftennotnecessary.Forpatientswithmoresevereepisodes,orthosewithoutthebenignclinicalpictureoutlinedabovethefollowinginvestigationsarereasonable:

• Fullbloodcountanddifferential• Urea&electrolytes,bloodglucose,• Nasopharyngealaspirateforviruses&pertussis.• ECG(measureQTinterval)

Iffebrile-alsofollowtheusualapproachtothefebrileinfantOtherinvestigationswhichmaybeconsideredinselectedcases:

• Investigationsforoccultfeaturesofnon-accidentalinjurysee• Metabolic:lactate,ammonia,acylcarnitineprofile• EEG• CThead• Holtermonitoring• Urinetoxicology/Metabolicscreen

InvestigationsforGastro-oesophagealrefluxareoftenunhelpfulseeManagementThismayincludeinitialresuscitation,and/ormanagementofanyidentifiedunderlyingaetiologyforthepresentation(egbacterialinfection,NAI)Needforadmission:Term-babieswithmoreminorpresentations(especiallyfeed-related),whoarewellonexamination,andwhoseparentscanbeappropriatelyreassuredandeducatedtoreturniftheyhavefurtherconcerns,maybedischargedwithrecommendationforearlyfollow-upwiththeirGPorapaediatrician.Inpracticemostbabieswiththispresentationareadmittedforobservation.Follow-upClosefollow-uppost-dischargeisrecommended,againlargelyforhelpingwithparentalanxiety.