UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK9–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)A29yearold is involved inhigh speedMCA.Onprimaryand secondary surveyhis injuriesappear tobe restricted to thethoraxandabdomen.

a. Statethree(3)abnormalfindingsshowninthisCXR.(3marks) • #Lmidclavicle• #Lscapulabody• #Lribs1-4• LULopacification(likelycontusion–“contusionisnotafindingitisaninterpretation”)• Widenedmediastinum

HisBPonarrivalis70/30.Hehasreceivednoprehospitaltreatment.b. Listthree(3)LIKELYcausesforhislowbloodpressure.(4marks) Anyof:• Massivehaemothorax• Aorticdissection(rupturelesslikelyasptwouldbedead)• Pericardialtamponade• Intraaabdominalinjury-rupturedspleen/kidneys/liver/bowel• Massivebloodlossfromexternalbleeding• Pelvic#

(NottensionPTXassaysBPonarrival,thereforebeforethisxrayhasbeenperformedoratleastatthesametime.CouldhavedevelopedsinceXR,butotheranswersbetter)

c. Statethree(4)KEYprinciplesfortheapplicationofmassivetransfusion.(3marks)

• Recognitionofbloodlossearly• Bettertostopbleedingthanreplacelosseswithblood/arrestbleedingwithearlysurgicalorradiologicalRx• Bloodproductsshouldbeusedearlyinseverehaemorrhage• Maintenanceoftissueperfusion/oxygenationbyrestorationofbloodvolume&Hb• Judicioususeofbloodcomponenttherapytocorrectcoagulopathy

d. Completethistabledemonstratingtheaimsforparametersinmassivetransfusion.(9marks)Parameter Aim

Temperature >35°CpH >7.2Baseexcess <-6Lactate <1.5-4(differentrecommendedtextsources)Ionisedcalcium >1.1Haemoglobin ShouldnotbeusedaloneasatriggerandspecificlevelcannotbedefinedPlatelets ≥50PT/APPT ≤1.5Fibrinogen ≥1Fromwww.transfusion.com.auAdditionalQs:1-Define“massivetransfusion”.(2marks)

• adult-replacementof>100%bloodvolume(3units)in24hoursor>50%ofbloodvolumein4hours(6units)• child=replacement>40ml/kg(bloodvol>1mthold80ml/kg)

2-Statethefrequencythatthesebloodtestsshouldberepeatedinthesettingofmassivetransfusion.(1mark)• 30-60minutely

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

Question2(18marks)A25yearoldrequiresintubationfollowingadrugoverdose.

a. Demonstrateyourfailedintubationalgorithm.

Initialfail

Callforhelp-1mark

BVMventilation+airwayadjuncts-(OPA,NPA)-1mark

Priorto2ndattempt–7marks

• Check-position-neckflexion,headextension• UtiliseCMAC• Laryngealtechnique• Alternativebladechoice• Externallaryngealmanipulation• Reviewsedation• Reviewmusclerelaxation

Maximum3(4)attempts-1mark

If3attemptsfail:

1mark

1mark 1mark

1mark

1mark 1mark 1mark

1mark 1mark

AdditionalQ:Listfour(4)KEYchecksthatyouwouldperforminthe10minutesafterestablishingappropriatepositionofanEndotrachealTubewithETCO2monitoring.(4marks)

• Tubesecured• Depthoftube• ETT/NGTpositiononCXR• Bloodpressure• ECGrhythm/ratechange• Oxygenation-sats• Ventilation

o ventilator-appropriateETCO2waveformo PIPS

• Sedationappropriate• NGTinsitu• Temperature-suddenincreasesuggestsmalignanthyperthermia• Anaphylaxis• ABG

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

Question3(12marks)

A23yearoldmanpresentswithageneralisedtonic,clonicseizure.

a. Definestatusepilepticus. (2marks) • Continuousseziure>5min

Or• Multipleseizureswithoutreturntonormalmentationbetweenseizures

(Timeframerecentlychangedfrom30minto5min)

b. OtherthanIdiopathicepilepsy/pre-existingseizuredisorder,listfour(4)MOSTLIKELYcausesforhisseizure.(4marks) • 1°brain

- headtrauma/SAH- CNSinfection- cerebrovascularevents- SOL/braintumour

• metabolic-↓ Na+,↓ glucose• drugwithdrawal-alcohol/benzos• druguse• toxins/overdose• pregnancy-eclampsia• sleepdeprivation

YouhaveIVaccess.

c. Assumingtheseizurecontinues,despiteyourtreatment,listtheagentsanddosethatyouwouldadministeratthespecifictimeframesstatedinthetablebelow.(6marks)

Timesinceonsetofseizure Agentstobeadministered(includedoses)

(6marks)0min

Dextrose50ml50%iflowBSLDiazepam5-10mgIVorclonazepam1mgormidaz5-10mg

5min

RepeatBzsamedose

10min

RepeatBzsamedoseLoadwithphenytoin15mg/kgtomaximum1gover1hour

20minute

Propofol2-3mg/kgorthiopentone2-5mg/kg

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Question4(12marks)

A2yearoldboypresentswithsuspectedKawasakisdisease.

a. Listthesix(6)criteriaforthediagnosisofKawasakisdisease.(6marks)• Fever>5days+4ofbelowcriteria:

- polymorphousrash- bilateral,nonpurulentconjunctivitis- cervicalLN>15mm- mucousmembranechanges- extremityerythema+oedema

b. List four (4) blood tests that support the diagnosis of Kawasakis syndrome and state the

expectedabnormality.(4marks)

Bloodtest ExpectedabnormalityWCC LeucocytosisPlatelets Marked↑in2ndweekESR ↑↑CRP ↑↑LFT ↑ASOT +veAnti-DNAaseB +ve

c. Listtwo(2)specifictreatmentsrecommendedinthetreatmentofapatientwithsuspected

Kawasakissyndrome. • Aspirin(5mg/kgOD6-8weeks)• IVIg(2g/kgover10hrs)

AdditionalQs:Listfour(4)epidemiologicalfeaturesofKawasakisdisease.(4marks)NB:Mostwillstrugglewiththis.Learnhowtouseyourclinicalknowledge.Reviewwhat“epidemiology”means.DefEpidemiology=isthesciencethatstudiesthepatterns,causes,andeffectsofhealthanddiseaseconditionsindefinedpopulations.

• Selflimitingvasculiticsyndrome• Unknowncause• 75%<5yrs• ↑incidenceinAsian/AfricoCaribbean• Malepredominance(1.5-2:1)• 10xincreaserisksiblings• Lowrecurrencerate<4%• Markedseasonality(Winter/SpringinAustralasia,SummerinAsia

Listtwo(2)possiblecomplicationsofKawasakisdisease. (2marks) • VasculitisCoronaryaneurysm,MI,peripherallimbischaemia,gangrene• Decreasedmyocardialcontractility• Valveregurgitation• Pericardialeffusion• Kshocksyndrome• Macrophageactivationsyndrome-DIC,cytopaenias,thrombosis• Suddendeath

Question5(12marks)

A54yearoldmanpresentswith1hourofcentralchestpain.

a. Statethree(3)abnormalitiesshownonthisECG.(3marks)

• STE4mmII,aVf,5mmIII• STE1mmRV4-6• STD2mmI,4mmaVl,1mmaVr,4mmV2

b. Statethree(3)SIGNIFICANTimplicationsofthesefindings.(3marks)• MeetscriteriaforurgentreperfusionRx• Rightventricularinvolvement

o preloadproblems-anticipatehypotensionandtreatwithfluidso bradyarrhythmias-anticipaterhythmdisturbance

Priortobeinggivenanymedications,hisbloodpressureisnotedtobe70/30mmHgwiththesamerateandrhythmasshownintheECG.

c. Assumingthatthebloodpressuredoesnot improve, list three(3)specific treatments forhisbloodpressure.Listone(1)justificationforeachchoice.(6marks)

Specifictreatment JustificationIVFluid/Crystalloid

VolumereplacementrequiredinRVinvolvementIncreasepreload

IVInotropes/Adrenaline

- Peripheraldose- PeripheralVC- ↑cardiacoutputbyimprovingcontractilityand

peripheralvasoconstrictionUrgentCathLab Iftheabovefail,onlyPTCA+/-balloonpumpwillbeeffective

AdditionalQ:List four (4)medications that youwould commence in theemergencydepartment.Providedoses foreachmedication.(4marks)

• Aspirin300mgPO• Ticagrelor180mgPO• IVHeparin4000-5000IUtheninfusion• IVfentanyl25mcgbolusorcarefulmorphine

GTNshouldbeavoidedduetopossibleseverehypotensioninRVinvolvement

(interpretation not specificallyaskedfor,butIwouldputthisin)

Question6(12marks)

A4yearoldboypresents1hourafterfallingfromaplaygroundslide.OnexaminationGCS12(E3,V3,M6)

a. Statefour(4)abnormalitiesshowninthisCTslice.(4marks)• 7x3cmnonhomogenoushyperdensecollectionc/wEDH-REQUIRED• M/Lshift• Sulcaleffacement signsof↑ICP• Ventriculareffacement • DecreaseinG-Wmatterdifferentiation

ThenearestNeurosurgicalfacilityis20minutesawaybyroadambulance.

b. Statefour(4)KEYprosforendotrachealintubationpriortotransfer.(4marks)• Definitiveairway-avoidairwayembarrassmentenroute/aspiration• Optimiseoxygenation• Optimiseventilation(ieavoidhypercapnia)• Sedationwill↓agitation∴ avoid↑ICP• Paralysisshould↓agitation∴ avoid↑ICP• FacilitaterapidtransfertoOT&surgery• Abilitytohyperventilateifnecessary

c. Statefour(4)KEYconsforendotrachealintubationpriortotransfer.(4marks)• Likelyto/willdelaytransfer• UnabletomonitorGCSand∴monitorfordeterioration• Haemodynamicsmaydeterioratewithsedation/ventilation• Oxygenationmaydeterioratewithsedation/ventilation• ICPmaydeterioratewithsedation/ventilation• Extubationrisk-bothaccidentalandwithplannedextubation

Question7(12marks)

A35yearoldmanpresentsfollowingstatedGamma-hydroxybutyricacid(GHB)use.

a. Listfour(4)expectedclinicalmanifestationsofGHBtoxicity.(4marks)

• Agitation-maybeperiodic/combatititveness• Myoclonus/seizures• Respdepression/apnoea• DepressedGCS/labilityinGCS/coma• Bradycardia• Hypotension• Nauseaandvomiting-aspiration• Hypothermia

PriortoIVaccess,thepatientbecomescombativeandstateshisintentiontoleave.

b. Listfour(4)KEYprinciplesintheprocessoftheapplicationofphysicalrestraint.(4marks)• Ptautonomyvsdutyofcare• Ptmustremainindept.untilassessmentcompleted-• Verbalde-escalationmusthavebeenattemptedandfailed

o Involvefamily/friendifpossible• Offeroforalchemicalrestraintofferedandfailed• Staffandpatientsafetyparamount• Adequatetrainedstaffshouldbepresent-security• Leastrestrictiverestraintthatcanbeusedtodetainptshouldbeused

o Inmostcasesthisis5pointrestraint• Mustdocumentdecisionandreasoning

c. Statefour(4)KEYstepsinyourapproachtochemicalsedationofthispatient. (4marks)

• Offeroral-Olanzepinewafer10mg• Acknowledgeanyhaemodynamic/consciousstatechangeREQUIRED

o TitratedownanyIM/IVmedicationgivenGHBonboard • IM(asingleacceptableoptionisok)

o midazolam5-7.5mgIM+/-Ziprasadone5mgoro lorazepam2mgoro olanzapine5-10mg

• EstablishIVaccesso TitrateIVmidazolam2mgaliqouts

• Headup/nurseat30-60degrees• Monitor-fullnoninvasive(cardiacrhythm,RR,O2sats,BP)• Documentdecisionprocess

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Question8(12marks)

a. Listfour(4)ultrasoundfeaturesofanormalappendix.(4marks)• Blindended• Aperistaltic• Arisesfromthebaseofthecaecum• Usuallyovoidinshape• Gutwalllayersidentifyitaspartofthebowel • Diameter<6mm• Compressible

b. Listsix(6)ultrasoundfeaturesofappendicealinflammation.(6marks)• Noncompressible• Rounderinshape• Transversediameter>6mm(>10suggestscarcinoid)• Lossofbowelwalllayersingangrenouschange• Appendicolith-ifvisualisedhighlyspecific• Indirectfeatures

o Freefluidadjacenttoappxo “creepingfat”o Regionallymphadenopathy

c. Statetwo(2)KEYprosofCTabdomeninthediagnosticprocessofsuspectedappendicitis.(2marks)Nb:Atleastoneofeachoptionmustrelatetodiagnosticutility. Not“cheap,available,lowradiation”

• Highsensitivityandspecificity• If-vemayavoid-velaparotomy/laparoscopy• AlternativeDxegColitis

o Visualisesretroperitoneum• Guidessurgicalintervention

d. Statetwo(2)KEYconsofCTabdomeninthediagnosticprocessofsuspectedappendicitis.(2marks)

• Radiationdose• Delayinsurgicalintervention• Longtimefromdepartment• Requiresspecialistinterpretation(NB:Oral/IVcontrastisnotrequiredtoDxAppx)

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Question9(12marks)A77yearoldmanpresentstoyouremergencydepartmentfeelinggenerallyunwellforseveraldays.Hisobservationsare:BP120/80mmHgsupineHR36/min.

a. Providefour(4)calculationstohelpyoutointerprettheseresults.(4marks)

Derivedvalues:• AnionGap-20• Deltaratio =∆Aniongap/∆[HCO3-]or↑aniongap/↓[HCO3-]

=Measuredaniongap–Normalaniongap =(AG–12) Normal[HCO3-]–Measured[HCO3-] (24-[HCO3-]) =20-12/24-14=8/10(HAGMA&NAGMA)Deltaratio AssessmentGuidelines

<0.4 Hyperchloremicnormalaniongapacidosis

<1 HighAG&normalAGacidosis

1to2 PureAnionGapAcidosisLacticacidosis:averagevalue1.6DKAmorelikelytohavearatiocloserto1duetourineketoneloss

>2 HighAGacidosisandaconcurrentmetabolicalkalosisorapre-existingcompensatedrespiratoryacidosis

• ExpectedCO229-adequatecompensation• A-agradient-154(expected23)• KcorrectedtopH=6

b. Usingthescenarioandthederivedvalues,definetheprimaryacid/baseabnormality/s.(2marks)• SevereHAGMA

c. Usingthescenarioandthederivedvalues,definethesecondaryacid/baseabnormality/s.(2marks)• NAGMA

d. Listone(1)LIKELYunifyingexplanationfortheseresults.(1mark)• Renalfailureleadingtodigoxintoxicityand↑K+• Digoxintoxicityaddingto↑K+

e. Listtwo(2)specifictreatmentsthatyouwouldinstituteintheemergencyDepartmentinthefirst1hour.

Provideone(1)justificationforeachchoice.(4marks) Treatment(2marks)

Justification(2marks)

Digibind10ampoulesasHDunstable30minutely

Antidotetoreverselifethreateningdigoxintoxicitywithbradycardiaandhyperkalaemia

IVNaHCO3orinsulin/dextrose

Rxhyperkalaemia

NB: Dialysiswillnotbeavailableinthefirst1hour CalciumiscontraindicatedinDigoxintoxicityandisafatalerror