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UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION

WEEK27–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)An8yearoldgirlpresentswithanasthmaexacerbation.

a. Stateone(1)keyproandone(2)keyconforeachofthelisteddeliverysystemsforsalbutamol,forthispatient.(6marks)

NB: Ptis8yrsold Avoidrepeatingthesamepointasaproforonetechniqueandaconforanalternativetechnique Youonlyget1-somakeitaclinicallyrelevantpro/con Avoidgeneric-egIVaccesscfspecificforIVsalbutamol

Deliverysystem Pro/cons(6marks)

MDIwithspacer

Pro:• Abletobedelivered/controlledbychild&parents• AllowsobservationofcorrecttechniqueandeducationwhileinED• ContinuecarethathasbeenefficaciousonD/c• Inmild→asefficaciousasnebs(level1evidence)• Lessconfrontingthanneb• Lowerdoseofventolindelivered-morelikelytoavoidsalbutamoltoxicity

Cons:• Cooperationrequired• Likelytobeineffectiveinsevere/criticalduetoinadequatetidalvolumes• Pooracceptanceifunfamiliar

Nebulised

Pro:• Efficaciousinsevereasthma-highdosewithflowpromotesinhalation• Lesscooperationneededbypatient• Lesseffortrequiredbypatient• Lesseffortrequiredbystaff• Deliverssupplementaloxygen

Cons:• Moreconfrontingthanspacer• Infectiousdiseasetransmissionviaaerosolspread• Higherdosesalbutamol-↑likelihoodsalbutamoltoxicity

Intravenous

Pro:• Rapideffectofbronchodilation• Abletoaccessentirelung-especiallyimportantifpoortidalvolumesorsegmentalcollapse• Doesnotrequireconsistentrespiratoryeffort• Dosetitration

Cons:• Salbutamoltoxicity-lacticacidosis,tachycardia,↓K,• Effectandthereforerisktoxicityamplifiedbyconcomitanttheophyllineuse• Greaternursingvigilancerequired

This8yearoldgirlpresentswithhermothertotheemergencydepartmentwitha1dayhistoryofshortnessofbreathandwheeze.ShehasapasthistoryofasthmawithonewardadmissionandonepreviousICUadmission,both2yearspreviously.HerusualmedicationsareSalbutamol(Ventolin)PRNandFluticasonePropionate(Flixotide)100mcgBD.Herinitialobservationsare:GCS15HR120/minRR40/minSpO291%RATemp37.0°CModerateaccessorymuscleuseTalkinginphrases.

b. Listtwo(2)medicationsthatyouwoulduseinthefirst20minutesofyourcare.Statedoseandroute.Provideajustification

foreachchoice.(6marks)Medication(2marks)

Dose(2marks)

Route(2marks)

Salbutamol 12puffs MDIspacerPrednisolone 2mg/kg(max60mg) OralAtrovent 6puffs MDIspacerDexamethasone 0.15mg/kg Oral

Thepatientrapidlybecomesdrowsyandexhaustedafteryourinitialtreatment.

c. Listtwo(2)medications,otherthanoxygenandsalbutamol,thatyouwouldcommenceonthispatient.Providedoseandrouteforeach.(6marks)

Medication(2marks)

Dose(2marks)

Route(2marks)

Aminophylline Load10mg/kgover60min IVMagnesiumsulphate 50mg/kgover20min IVipratropium 250mcg20minx3 NebulisedMethylpred 1mg/kg IV

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

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RCHasthmaMxguideline

Severity SignsofSeverity Management

Mild NormalmentalstateSubtleornoincreasedworkofbreathingaccessorymuscleuse/recession.Abletotalknormally

SalbutamolbyMDI/spacer(dosebelowtable)-giveonceandreviewafter20mins.Ensuredevice/techniqueappropriate.Goodresponse-dischargeonB2-agonistasneeded.Poorresponse-treatasmoderate.Oralprednisoloneforacuteepisodeswhichdonotrespondtobronchodilatoralone-2mg/kg(max60mg)initially,onlycontinuingwith1mg/kgdailyforfurther1-2daysifthereisongoingneedforregularsalbutamol.Providewrittenadviceonwhattodoifsymptomsworsen.Consideroverallcontrolandfamily'sknowledge.Arrangefollow-upasappropriate.

Moderate NormalmentalstateSome↑WOBaccessorymuscleuse/recessionTachycardiaSomelimitofabilitytotalk

OxygenifO2saturationis<92%.NeedforOxygenshouldbereassessed.SalbutamolbyMDI/spacer-1dose(dosebelow)every20minutesfor1hour;review10-20minafter3rddosetodecideontimingofnextdose.Oralprednisolone-2mg/kg(max60mg)initially,onlycontinuingwith1mg/kgdailyforfurther1-2daysifthereisongoingneedforregularsalbutamol.

Severe Agitated/distressedModerate-markedincreasedworkofbreathingaccessorymuscleuse/recession.TachycardiaMarkedlimitationofabilitytotalkNote:wheezeisapoorpredictorofseverity.

OxygenasaboveSalbutamolbyMDI/spacer-1dose(dosebelow)every20minutesfor1hour;reviewongoingrequirements10-20minafter3rddose.Ifimproving,reducefrequency.Ifnochange,continue20minutely.Ifdeterioratingatanystage,treatascritical.IpratropiumbyMDI/spacer-1dose(dosebelow)every20minutesfor1houronly.AminophyllineIfdeterioratingorchildisverysick.Loadingdose:10mg/kgi.v.(maximumdose500mg)over60min.Unlessmarkedlyimprovedfollowingloadingdose,givecontinuousinfusion(usuallyinICU),or6hourlydosing(usuallyinward).DrugdosesMagnesiumsulphate50%(500mg/mL)Diluteto200mg/mL(byadding1.5mlsofsodiumchloride0.9%toeach1mlofMgSulphate)forintravenousadministration

• 50mg/kgover20mins• IfgoingtoICU,thismaybecontinuedwith30mg/kg/hourbyinfusion

Oralprednisolone(2mg/kg);ifvomitinggivei.v.methylprednisolone(1mg/kg)Arrangeadmissionafterinitialassessment.

Critical Confused/drowsyMaximalworkofbreathingaccessorymuscleuse/recessionExhaustionMarkedtachycardiaUnabletotalkSILENTCHEST,wheezemaybeabsentifthereispoorairentry.

OxygenContinuousnebulisedsalbutamol(use2x5mg/2.5Lnebulesundiluted)-seebelowretoxicity.Nebulisedipratropium250mcg3timesin1sthronly,(20minutely,addedtosalbutamol).Methylprednisolone1mg/kgi.v.6-hourly.AminophyllineasaboveMagnesiumsulphateasabove.InICUpatientsonMginfusion,aimtokeepserumMgbetween1.5and2.5mmol/L.Mayalsoconsideri.v.salbutamol.Limitedevidenceforbenefit.5mcg/kg/minforonehourasaload,followedby1-2mcg/kg/min.Bewaresalbutamoltoxicity:tachycardia,tachypnoea,metabolicacidosis.CanoccurwithbothIVandinhaledtherapy.Lactatecommonlyhigh.Considerstopping/reducingsalbutamolasatrialifyouthinkthismaybetheproblem.Aminophylline,magnesiumandsalbutamolmustbegivenviaseparateIVlines.Intensivecareadmissionforrespiratorysupport(facemaskCPAP,BiPAP,orintubation/IPPV)maybeneeded.

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Question2(12marks)A24yearoldmanpresentsbyambulancefollowingasinglestabwoundtothechest.Vitalsignsonarrivalare:BP165/80mmHgHR125/min(sinusrhythm)RR26/minO2sats97%RAGCS15

AbedsideECHOconfirmscardiactamponade.ImmediatelyaftertheECHOisperformedthepatientrapidlybecomesunconscious.RepeatBPisBP60/20mmHgHRwith140(sinusrhythm).

a. List four (4) factors in this presentation that are associated with a good outcome fromemergencythoracotomy.(4marks)

• Isolatedchestinjury• Singleinjury• Penetratingwound• Stab(betterthanGSW)• Normalvitalsignsonpresentation• Presenceoftamponade

b. Listfour(4)specificproceduresthatemergencythoracotomyallows.(4marks)

• Preicardotomyfortamponade• Controlcardiacbleeding• Compress/clamppulmonarytrunk• Compress/clampdescendingaorta• Opencardiacmassage• RAaccessforIV(!)

YouconsiderperformingEmergencythoracotomyintheEmergencyDepartment.

c. Listfour(4)constoperformingthisprocedureonthispatient.(4marks)• Operatorskill• Riskneedlestick/splash/bloodeverywhere• lackofbackupthoracic/surgerytodefinitivelyMxinjuries• lackofappropriateequipment

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Question3(11marks)A21yearoldmanisbroughttotheemergencydepartmentbyambulanceafteranMVArolloverwherehewastheunrestraineddriver.Hisobservationsare:GCS8(E2,M4,V2)BP80/50mmHgHR50beats/minO2Saturation91%on15L/minO2vianon-rebreathermask

a. Statefive(5)abnormalfindingsshowninthisxray.(5marks)

NB:ThispropwasusedpreviouslyasaVAQ-Theexaminersagreedthatthemajorabnormalitiesonthefilmwereeasilyidentifiableandtheseriousnatureoftheinjuriesandtheirconsequencesdemandedahighlevelresponsefromcandidates.

• PosteriorshiftofC5onC6~25%vertebralbodywidth• Displaced,anteriorflexionteardropfractureofC5• #C5+C6spinousprocess• DisruptionofanteriorspinallineatC5/6• DisruptionofposteriorspinallineatC5/^• Disruptionspino-laminalline• Softtissueswelling2.5cmatC4

Betteranswersincludedquantificationofthefindings(e.g.amountofsofttissueswelling;amountofdisplacement),eitherbydirectmeasurement(e.g.inmillimetres)orbycomparisonwithvertebralbodywidth.Themostcommonfeaturesofunsuccessfulanswerswerefailuretoidentifyatleastoneofthelistedcriteria.Indeed,mostunsuccessfulanswersactuallyfailedtomentiontwoormoreofthesecriteria.Themostcommonwerepoorterminologyusedindescribingtheabnormalities.Evenmoresurprisingly,somecandidatesgotthelevelofinjurywrong!Thiswasconsideredsuchabasicessentialskillthatitwasviewedverypoorlyinthis,aconsultantlevelexam.

b. Isthisinjuryastableorunstableinjury?(1mark)

• Unstablec. Stateone(1)justificationforyouranswerin“b”.(1mark)

• Anteriorandposteriorlongitudinalligamentdisrupted/“3pillar/column”injury

d. Listfive(5)LIKELYcomplicationsof/orproblemswithcervicalimmobilisationforthispatient.(5marks)• CxCollar:

o Patientdiscomfort-HA,mandibularpaino Worseningneurologicalfunction-immobilisationmaynotbeinneutralpositiono ↓accesstoneck/occiput-↓visualisation,accesstoEJV&IJVo Cutaneouspressureulcerationo ↑intracranialpressure-fromCxcollars-averageof2-5mmHg-maybeupto15mmHgo ↑difficultyofintubation

• Aspirationrisk• DVTrisk

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Question4(12marks)

a. Listone(1)clinicalfeatureofeachstatedHydrofluoricAcidexposure.(4marks)

Clinicalfeature

Dermal • Severeunremittingpain• Blistering/tissueloss• Maytakeseveralhoursforskinsignstodevelop(initiallynoobviouserythemaor

blistering)Inhalational • Oropharyngealdiscomfort

• NoncardiogenicAPO• Immediateonsetofmucosalirritation• DelayedonsetofSOB,cough,wheeze

Ingestion • Mildthroatpain• Lowconcentrations(<20%)areminimallycorrosivetoGIT• Dysphagia• Vomiting• Abdopain• Cardiacarrest-Arrestfromsystemicfluorosiswithoutwarningfrom30min-6/24

Systemic • Systemicfluorosis• Ventriculararrhythmias• ↓Ca/↓Mg→tetany/QTprolongation• Cardiacarrest

b. Listthree(3)differenttechniquesfortheadministrationoftheantidotetoHydrofluoricacidexposure

andgivedetails.Provideone(1)proforeachtechnique.(9marks)NB:again,trytoavoidrepeatingthesamepointasaproforonetechniqueandaconforanalternativetechnique.

Technique Pro Con

Topical • Lessinvasivecfothertechniques

• TopicalRxislimitedasskinisrelativelyimpermeabletoCa

• Tissuenecrosis(CaGluconateispreferredtoCaClasthehigherconcentrationofCaisveryirritanttoskin)

S/cinfiltration(5%viafineneedle)

• Rapidreliefofpain(1stlineRxifsmalleffectedarea)

• AmountofCadeliveryislimited(maxdose1ml/cm2ofaffectedtissue)• InitialpainfromfreeCaions• ↑tissuedamageifCa>Fland∴ free/unbound

Ca• Excessivedigitinjectionmaycompromise

circulationIV • ↑penetrationofCaionsto

affectedtissue• TechnicallyeasierthanI/A

(requiresIVandBPcuffonly)

• Ischaemicpainresults∴ difficulttoassessifRxeffective(resolutionofpainisthemostimportantmarkerofsuccessfulRx)

• Poorptacceptance• Rxtimelimitedbylimbischaemiatime• Risksystemic↑Caifcuffdeflates

IA(Caglucdilutedin5%D)Rxover2-4/24)

• MosteffectiveRxforsystemicfluorosis

• DeeptissueinfiltrationofCaionsmayexacerbatetissuedamage

• Riskarterialspasm/thrombosis→limbischaemia• Resourceintensive• RequiresICUadmissionpost

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Question5(12marks)a. Listfour(4)medical/surgicalconditionsthatrequirelowaltitudeinthesettingofretrieval.(4marks)

• #skull/penetratingheadinjuries• Aerocele(CI)• RecentGITsutures• Bowelobstruction• Mediastinalemphysema• PTXnotRxwithICC• Penetratingeyeinjury• DCI• AnaemiaHb<7.0• Acutecoronarysyndrome• (spinalinjuries-lowerGforcesforhelicoptercffixed)

b. Otherthanpressurisationissues,statefour(4)specificproblemswithfixedwingasamodalityforretrieval.(4

marks)• Space,Access

o Limitedspace,lighting,facilitiesforinterventionso Equipment→space,weight,secureinflight

• Infusionswithdripchambers→dysfunctionalinturbulence,oftenfailduringacceleration/deceleration

• Defibrillationo ifhighriskforarrhythmias→applyselfadherentpadspriortodeparture,preinformpiloto problemwithresidualcurrentleak→maydisableelectronicequipmento ∴pilotmustbeconsultedpriortoanyattempt,mayneedtoturnoffsomeequipment→final

decisionispilots• Motionsickness→antiemeticsearly• “Sopitesyndrome”→yawning,drowsiness,disinclinationforphysical/mentalwork

o notdirectlyrelatedtodegreeofturbulenceo unresponsivetoanti-motionmedso littleadaptionwithtime

• Dangerfromagitatedpatients• Noise,vibration

o communication,missingalarmso fineproceduresdifficulto needconstantvigilance→useofvisualsigns(egchestwallmvt)

• Communicationo Patient,pilot,receivinghospital

• Acceleration,decelerationandturbulence• Extremesoftemperature,humidity• Electromagneticinterferencebetweenavionicsandmonitoringdevices• Dangerfromloose,mobileequipment• Positioning→severeCHI→placeheadforwardsattakeoffandtowardstailatlanding• DelaysinlandingEgfromweatherconditions,mustbepreparedforprolongedMx• Notaseasilymobilised• Needsairstrip• Roadtransportrequiredateachend

c. Listfour(4)specificproblemswithrotarywing(helicopter)asamodalityforretrieval.(4marks)

• Limitedflyingtime2/24or200km• Highnoiselevels→ communicationonlyviaheadset• Sizelimitation-spacelimitedforequipment• Weightrestrictionscritical• Usuallynotpressurized• Temperature→ difficulttomaintaincabinpressure• Weather/nightflyingrestrictions• Slowerflyingspeedcffixedwing• Expense• Rotorclearance→ IVpolesetc

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Question6(11marks)

a. ListthecriteriathatarerequiredintheCDC(CentreforDiseaseControlandPrevention)definitionofanAIDScase.(3marks)

• HIVinfected• Witheither:

o CD4Tlymphocytecount<200 Or

o Defined-opportunisticinfectionb. CompletethetablebelowwithrespecttoHIVinfection,bylistingone(1)clinicalfeatureand

CD4countrangeforeachstageofHIVinfection.(8marks)

WorldHealthOrganisationclinicalstage

Clinicalfeature

(4marks)

CD4count

(4marks)

1 • Asymptomatic• PersistentgeneralisedLN

>500

2

• Mildsymptoms• Moderatewtloss• RecurrentRTI• HZ• Angularchelitis• Recurrentoralulceration• Seborrhoeicdermatitis• Fungalnail

350-499

3

• Severewtloss• ChronicDs>1/12• Persistentfever• Oralcandidiasis• PulmonaryTb• Severebacterialinfection• Ulcerative

stomatitis/gingivitis• Anaemia• thrombocytopaenia

200-349

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• Severesymptoms• AIDSdefining:

o PCPpneumoniao CerebralToxoo Encephalopathyo CMVretinopathyo Kaposissarcomao Tbo Cryptococcalmeningitis

• HIVwastingsyndrome

<200

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Question7(12marks)A75yearoldpresentswithapainfulrighteye.Yoususpectacuteangleglaucomaasthemostlikelydiagnosis.

a. Otherthanage,listthree(3)riskfactorsforthedevelopmentofacuteangleglaucoma.(3marks)

• Shallowanteriorchamber(!)• Anticholinergicdrugs-atropine,Atrovent• Betaagonists• Mydriatics• ↑lensthickness• FHx• Ethnicpredisposition-SEAsia• Female3x>male

b. Otherthanthepresenceofariskfactororprevioushistory,listthree(3)historicalfeatures

thatwouldbeconsistentwithadiagnosisofacuteangleglaucoma.(3marks)• Severeunilateralpain• OnsetpostwatchingTV,lyingfacedown• Visualdisturbance-classically“visualhalo”• +/-N/V

c. Listthree(3)examinationfeaturesthatwouldbeconsistentwithadiagnosisofacuteangle

glaucoma.(3marks)• IOP>30mmHg• Semidilated,nonreactivepupil• Cornealhaze• Perilimbicconjunctivalinjection• Shallowanteriorchamber

d. Otherthananalgesics,listthree(3)drugsthatyoumaycommenceforthispatient.(3marks)

NB:dosesnotrequested∴notrequired• Acetazolamide(500mgIV)• Mannitol(1g/kg)• Pilocarpine(2%every5minfor1/24)• Timoptol(0.5%Idropevery30min)• Antiemetic(notmaxolon)

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Question8(12marks)a. Listthree(3)prostothepracticeofassigningATS2toalladultpatientswhopresentwithchestpain.(3marks)NB:TriageiscoveredwellinbothDunn&Cameron

• Clinicalsafety-Worst-casescenariotypicallyassumed• ↑sensitivity-lowfalse-verateforseriousillness• Highpick-uprateforseriousconditionslikeSTEMI• Optimaluseoflimitedresources• Standardisationofcare• Validity• Reliability• Acceptability• Amplescopeforresearch:automaticallycategoriseddata• Abilitytomeasureandbenchmark-Permitsmeasurementofhealthcareaccessandefficiency:ATSisintegralto

severalEDperformancemeasures

b. Listthree(3)constothepracticeofassigningATS2toalladultpatientswhopresentwithchestpain.(3marks)• ↓specificity-high“falsepositive”rate• Highresourceconsumption-directsresourcesfromother,equallydeservingcases• Noevidenceonvalidity&reliabilityoftriageforchestpain• Statisticalanalysisissues:

o ATStoosimplisticameasureofhealthcare–leadstoinaccurateassessmentso Mayaffectfundingo Assumesallhealthcaresitesareequal,incasemix&resources

AsdutyconsultantinatertiaryED,youhavejustarrivedforhandovertoalateshiftonMondayevening.Thedepartmentisfull.Therearenomonitoredorgeneralcubiclesavailableandthewaitingroomisfull.Yourmedicalstaffarecurrentlyoccupiedwithseveralhigh-acuitycases.3ambulancecaseshavejustarrived,andarewaitingtobetriagedinthecorridor.Ofthese,onepatientlookstobeinpain;anotherappearsshortofbreath.

c. Statethree(3)optionsforthecareofthesepatients.Provideone(1)proorconforeachoftheseoptions(statewhetheraprooracon).(6marks)

Optionforcare Justification

Deferallinterventionuntilcubiclesavailable

Pro:• LeavesresponsibilitywithambulanceCon:• delaysemergencytreatment• keepsambulanceresourceoffroad• negativeeffectsonrelationshipwithambulance

Initiatenursingtriageandregistrationontrolleys

Pro:• allowsdetailedriskassessmentandprioritisation• allowssimpleinterventionssuchasanalgesiaandfasttrackIxCon:• Limitedinvalue• BlursdelineationbetweenambulanceandEDresponsibilities

Medicaltriageandtreatmentontrolleys

Pros:• ShouldimproveprocesstimesdownstreamCons:• Delaysdepartmentalhandover• Mayleadtoinappropriatebedmoves(ienotawareofsituationofotherpts)• Marginalvalueadded• Consumesadditionalresources• Potentialconfusionbetweennursingandmedicalroles.

Clearacubicleanduseasrapid(in-out)assessmentarea

Pro:• Permitsmoredetailedassessment• PrivacyCon:• Consumptionofpreciousresource• Corridoronlytemporarilyrelieved

Clear3cubiclestooffloadpatients,pernormalprocesses

Pro:• Idealoption• All3casesarelikelytoneedcubicle!Con:• Leastfeasible,givencurrentcircumstances• Case(s)mayneedmonitoringthatisbeingprovided,butmaynotbereadilyavailable

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Question9(17marks)A64year-oldmanpresentstoyourEmergencyDepartmentwithdyspnoeaandpalpitations.HispasthistoryincludesCOPD,chronicrenalfailure,obesity,IHDandhypertension.Vitalsignsonpresentationare:GCS15BP88/60mmHgRR20bpmO2sats88%RATemperature 36°C

a. Statesix(6)abnormalECGfindings.(6marks)

• Rate~155• BroadQRS~160• AVRgrossly+ve• NW/extremerightaxis• PeakedTwaves• STchanges-interpretationdifficult

Avenousbloodgasisperformed:pH6.9(7.35–7.45)pCO260mmHg(35–45)pO228mmHgHCO310mmol/L(22–33)BE-10(-3–+3)K+8.6mmol/L(3.5–

5.5)b. Listthree(3)keyabnormalitiesinthisbloodgas.Stateone(1)pointtodemonstratethesignificanceof

eachabnormalityforthispatient.(6marks)

Abnormality(3marks)

Significance(3marks)

pH6.9/HCO310 • Profoundacidaemia• Mixedmetabolic&respiratoryacidosis• Metaboliclikelytoberelatedtorenalfailure• Highmorbidity/mortality

CO260 • IndicatestypeIIrespiratoryfailure• Potentialcause(likelycombination-CRF,IHD,sedative

meds(egnarcotics,Pickwickiansyndromefrommorbidobesity

K+8.6 • Severe/lifethreatening• MayaccountforVT• CalculatedK+elevatedbylowpH(predicted6.1if

normalisedto7.4)• Requiresurgentcorrection

c. Listfive(5)medicationsthatyoumayprescribeforthispatient.(5marks)

• CaGluconate/CaCl(unlessdigtoxicitypossible)• DigibindifDigtoxicity• NaHCO3(8.4%100ml)• Insulin(10IU+50mls50%D)• Salbutamol(neb5mg)• Resonium(rectal)

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au April2018