th Oct 2020 (answers below) 1. Outline your management of ...
5
QUIZ 28 th Oct 2020 (answers below) 1. Outline your management of epistaxis. 2. Describe the steps to insert a Rapid Rhino. 3. What discharge instructions do you give epistaxis patients? 4. What laboratory parameters should be monitored to guide ongoing massive transfusion? 5. Describe and interpret the following ECG.
Transcript of th Oct 2020 (answers below) 1. Outline your management of ...
QUIZ28thOct2020(answersbelow)
1. Outlineyourmanagementofepistaxis.
2. DescribethestepstoinsertaRapidRhino.
3. Whatdischargeinstructionsdoyougiveepistaxispatients?
4. Whatlaboratoryparametersshouldbemonitoredtoguideongoingmassivetransfusion?
5. DescribeandinterpretthefollowingECG.
QUIZanswers28thOct2020
1. Outlineyourmanagementofepistaxis.
A. ResuscitationParticularlyinsevereorprolongedepistaxis,considerneedfor:
• Airwaymanagement• Bloodtransfusion/MTP/Anticoagulationreversal• UrgentENTconsultation
B. Firstaid–(patientscanbeinstructedtodothisifithappensagain)GentlyblownosetoclearclotsPinchtheSOFTsidesofthenoseagainsttheseptumHoldfirmpressurecontinuouslyfor10minutesSitupandleanforward,spitoutanybloodinmouth+/-Coldcompressacrossbridgeofnose
C. ExaminationTrytodeterminewhichsidethebleedingstartedfromClearclotsout–bypatientgentlyblowingnose,orusesoftYsuctioncathetersnippedshortersothattherearenosideholesSprayCoPhyenycaineone/bothsidesVisualiseaffectedsidelookingforbleedingsite
HeadlightNasalspeculumMayneedmoresuctioning,wipingwithswab
D. OngoingbleedingCottonwoolpledgetssoakedinadrenaline1:1000
Patientcanapplyfirstaidpressurewithpledgetinplace10–20minCanalsotrypledgetsoakedintranexamicacid
*ConsiderposteriorbleedingUsuallynotminorbleeding
Bleedingfrombothnostrils Noanteriorsitefound Patientfeelsblooddrippingdownoropharynx
E. CauteryIfbleedingsitefound,cancauterizewithsilvernitratestick
Riskofperforationisonlyifcauterizingseptumbilaterally Thenapplysmallfoldedpieceofsurgicelanddischargeinstructions
F. PackingwithRapidRhinoOnlyiffailureofabovemeasuresCommitspatienttoadmissiontohospitalConsiderENThelppriortoinsertionasitcausestoomuchmucosaltraumatoremoveagainstraightawayforreexamination
2. DescribethestepstoinsertaRapidRhino.Ø Removebluecover
Ø Soakinsterilewaterforafull30seconds§ Don’tusesalineasitinhibitsthegellingcharacteristicsof
thefabric.§ Don’tuselubricantorantibioticointment,astheywill
inhibitthehaemostaticpropertiesofthefabric.
Ø Insertthedevicealongtheseptalfloorandparalleltothehardpalateuntiltheplasticproximalfabricringiswellwithinthenares.
Ø Usea20mLsyringeandinflatethedevicewithAIR.§ Stoptheinflationwhenthepilotcuffbecomesroundedand
feelsfirmwhensqueezed.§ Theamountofairdependsonthesizeofthepatient’s
nasalanatomy.
Ø Tapethepilotcufftothesideofthepatient’sface.
3. Whatdischargeinstructionsdoyougiveepistaxispatients?
Forthenext3days:Avoidexertion,strainingandheavyliftingAvoidsteaminghotfood,drinksandshowersAvoidnoseblowingUsevasoconstrictoreg.DrixineUsemoisturiseronnasalmucosabd
eg.Nasalate,chlorsigointment,bactroban,vaseline Providefirstaid(asabove)ifrecursandreturnifepistaxispersists
4. Whatlaboratoryparametersshouldbemonitoredtoguideongoingmassivetransfusion?
pH >7.2 Baseexcess <-6 Lactate <4mmol/L iCa >1.1mmol/L Hb Shouldnotbeusedaloneasatransfusiontrigger Platelet >50x109/L PT/APTT <1.5normal INR <1.5 Fibrinogen >1.0g/L
5. DescribeandinterpretthefollowingECG.
Rate 88/min SinusrhythmwithfrequentPVCsandfusionbeats
ThePVCsarefollowedbyacompletecompensatorypause,indicatingthatthesinustimingisnotinterrupted;onesinusPwaveisn'tabletoreachtheventriclesbecausetheyarestillrefractoryfromthePVC;thefollowingsinusimpulsecontinuesthesinusrateof88/min.
Pwaves NormalmorphologyPRinterval NormalQRS Narrow,normalaxis,normalaxis,normalRwaveprogressionSTsegments Depressedinferiorly(III,aVf,II) DepressionV4-5atJpoint,slopinguptoupright,symmetricalTwaves Elevation1mminaVR ElevatedV1-3leadinguptolargehyperacuteTwavesQTc Prolonged484msec
è CoronaryangiogramrevealedcompleteproximalLADocclusion
Thispatternof1-to3-mmupslopingST-segmentdepressionattheJpointinleadsV1toV6thatcontinuedintotall,positivesymmetricalTwavesisconsistentwith“deWinterTwaves”andindicatesproximalLADocclusion.Inmostpatients,thereisalso1-to2-mmST-elevationinleadaVR.DeWinderRAnewECGsignofproximalLADocclusionNEnglJMed2008;359:2071-2073
