UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION

WEEK20–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)A30yearoldwoman,G1P0whoiscurrently36weekspregnant,presentstoyouremergencydepartment.a. Listthree(3)physiologicalchangesthatyoumayexpecttoseeinherECG.(3marks)NB:changesareduetocephalicdisplacementofheart

• Sinustachycardia• LADby15°• Tinversion/flatteningIII,V1,V2• QAVF• SVTmorecommon

Thepatientpresentedwithaconcernof1weekofincreasingdyspnoeaandchestdiscomfort.Herpregnancyisotherwiseprogressingnormally.Sheispreviouslywell,withnosignificantpasthistoryandshetakesnomedications.Herobservationsonarrivalare:BP110/60mmHgRR30/minOxygensaturation98%onroomairGCS15Temp37.8°C

b. Statefour(4)abnormalitiesshowninthisECG.(4marks)

• Sinustachycardia(NBthereissubtleirregularitybutonly1pwavemorphologysocantbeMFAT)• Rate110-130acceptable• PeakedpwavessuggestiveofRatrialenlargement• RAD• STDII,III,aVF,2mmV3-V61mm• STEaVR1mm• TWbiphasicII,III,AVF

c. InterpretthisECGforthispatient.(2marks)

NB:thisisNOTnormalforpregnancy• “pulmonarypattern”suggestiveofrightheartstrain• stronglysuggestiveofsubmassive/massivePE(Notjust“PE”)

d. Completethetablebelowbystatingfour(4)investigationoptionsthatmayassistwithconfirmationofthediagnosisinthispatient.

Alsolistonesignificantproandoneconforeachinvestigationinthispatient.(6marks)

NB:BothCTPAandVQareofthoughttobeofsimilarradiationthreat–thejuryisstilloutandthereforealessthantheotheranswermustbeacceptable.CTPAconsideredlessradiationtofoetusandVQconsideredmoreradiationtothemother.Only1“clinicallyuseful”pro/conrequired-stressfocusonclinicalrelevanceofpro/con(notjust“simple”“cheap”“available”)Shouldnothavethesameproorconfordifferenttests

Investigationthatmayassistwithdiagnosisconfirmation

Pro Con

CTPA DefinitiveIxCandefine/excludemultipleDxLessradiationtofoetuscomparedtoVQ

SignificantradiationtobreastSignificantcontrastContrastallergyAcuterenalinjury

VQ LessradiationtomothercomparedtoCT

MaybeindeterminantBreastartefactSignificantradiationtobaby

TTECHO NoradiationBedside+vesupportiveonly

SupportiveonlyoftheDx,notDx-veneedsfurtherIxOperatordependentBodyhabitusdependent

LowerlimbUS NoradiationUsefulifpositive-supports

-vedoesnotexclude(maybepelvicvclot)

CXR MinimalradiationMaydiagnosealternative(egTensionPTX)

Poorsensitivity

ABG Hypoxaemiasupportssub/massivePERaisedA-agradient

PainfulSupportiveonly

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

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Question2(12marks)A9montholdboyisbroughtintoyouremergencydepartmentbyhismotherafterhebecamedistressedathome.

a. Statefour(4)relevantpositiveornegativefindingsinthisxray.(4marks)

• Spiral#midshaftrightfemur,mediallyangulateddistalsegmentat~30˚toproximalsegment

• Nootheracute#• No#ofotheragesorsignificantcallouspresent• Nopelvicshielding(maybeappropriatetoallowexclusionofother#)

b. Listfour(4)relevanthistoricalfactorsthatyouwouldseekinthiscase.(4marks)

NB:FocusneedstoacknowledgesuspicionofNAIHxofevent:

• Statedmechanismofinjury• CollateralHxfromotherstoassess-consistencyinHxbetweenindividuals• Whowasprimarycarerattimeofinjury• Timeframetopresentationfromstatedtimeofinjury

HxRFforNAI:• PriorDHSinvolvementwithfamily/otherchildrenidentifiedpreviouslyasbeingatrisk• PMHxcongenital/anatomicalabnormalities• Antenatal/birthHx• Social-sizeoffamily(Increasedriskwithincreasedfamilysize)• Socioeconomicstate(lowSESincreasedrisk)• Parentalmental/physicalillness• Parentalsubstanceabuse

c. Otherthanexaminationofthelimbinvolved,listfour(4)specificexaminationfindingsthatyouwouldseekin

thiscase.(4marks)• GCS• Generalbehaviours-egcrieswhenbeingheld• Bruising-espdifferentages• Abdotenderness• Oral-tornfrenulum,palatalpetechiae• Genitaltrauma• Retinalhaemorrhages• TMbruising• FWT-haematuria• Developmentaldelay

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Question3(12marks)A68yearoldmanisbroughtintoyouremergencydepartmentviaprivatecarfromaQueenslandbeach.

a. Whatisthelikelyorganisminvolvedinthiscase? (1mark)• Boxjellyfish

b. Listthree(3)acutecomplicationsofthiscondition. (3marks)• Immediate,severepain• Lymphadenopathy• Fatatrophy• Vasospasm-limbnecrosis• Hypotension• Hypertension• Tachycardia• VT• VF• Death

c. Listthree(3)longtermcomplicationsofthiscondition?(3marks)

• Delayedhypersensitivityreactions-pruritic,erythemaatthesite• Keloidscarring• Hyperpigmentation• Autonomicparalysis• Ataxia

d. Listfive(5)currentcontroversiesinthemanagementofthiscondition.(5marks)

• Antivenomtiming-?prehospitaladministration• Antivenomuseatall(ProlongedACLSiseffectiveinabsenceofantivenom)• Icevsheat• Magnesiumrole• Vinegarrole(stopsnewnematocystsfiringbutshowntoincreaseeffectofalreadyactivated

nematocysts)

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Question4(12marks)Youarepreparingtoperformarapidsequenceintubationfora65yearoldwoman.

a. Statefive(5)clinicalfeaturesthatyouwouldreviewtodeterminewhethershewillbeadifficultintubation.(5marks)Ensurethatyouhaveastructure-either“LEMON”or“anatomical,physiological,pathologicalL–Lookexternally-Isthepatientobese,dotheyhaveahigharchedpalate,ashortneck,facialornecktrauma?E–Evaluatethe3:3:2rule-3cmmouthopening,3cmthyromentaldistance,2cmbetweenhyoidboneandthyroidnotch.Ifunsureastohowmuchacmis,justusethe3fingersor2fingersapproachM–MallampatiScore-rememberaMallampati4isassociatedwitha>10%chanceofdifficultairwayO–Obstruction–Isthereatumour,epiglottitis,recentnecksurgery?N–Neckmobility–Isthepatientinacervicalcollar,aretheyelderly?Anatomicalvariations

§ mandible-inabilitytoopenmouth>3fingerbreath/receedingchin§ protrudingteethmacroglossiadeep,narrow,higharchedoropharynxMallampatiClass3or4§ thyromentaldistance<3fingerbreaths(<~6cm)

§ neckabnormalities-short/thick,↓ ROM(Atlanto-occipitaljtext.<30o)§ thoraco-abdominal-kyphoscoliosis/largebreasts

Physiologicalvariations§ obesity/pregnancy§ children

Pathologicalvariations§ Stridor/hoarsevoice§ Facial/necktraumaordisease§ deformity,burns,XRT,infection,swelling,esp.laryngealtrauma§ ImmobilizedCspine

b. Statefour(4)stepsthatyouwouldtakeifadifficultairwayisidentified.(4marks)

• Reviewnotes-priordevices/techniquesthathavebeenuseful• Additionalassistanceearly• Considerfibreopticguidedintubation• UtiliseCMAC• Optimisepatientpositioning• Assembledifficultairwayequipment• Considerketamineorgaseousinduction• Haveseconddoseinductionagentavailable• Planforfailure• Dedicatedpersonpreparedforimmediatesurgicalairway

c. Statethree(3)methodsthatyoumayutilisetoconfirmcorrectendotrachealtubepostintubation.(3marks)

Best:(bothrequiredtopass)§ ETCO2levelorwaveform-Consideredgoldstandard-MANDATORY§ Directvisualisationofthetubepassingthroughcords.MANDATORY

OtherIndicators:§ Chestrisessymmetricallywithventilation.§ Auscultation:

o Bilateralandequalbreathsoundsonauscultation(listenatbothapicesandhighineachaxilla).o Alsolistenoverepigastrium(isETTinthestomach?)

§ Wee’stest:o readyaspirationof50mlsofairmeansthatthetubeisinthetrachea.Ifaircannotreadilybe

aspirated,thentubeismorelikelyintheoesophagus.ThistestcanbedonewithaTwomeysyringeOtherLessReliableIndicators:

§ The‘feel’ofventilation.§ Observingescapeofair/moisturecloudingonthelucenttube.§ Singsofhypoxia/cyanosis(alwaysassumethisisduetotubepositioninfirstinstance.Thisisalatesign)NB:CXR:thismaysuggestthatthetubeisinwrongplace(eg.downrightmainbronchus,orwellpastthe

carina).Itcannotprovethatitisinthecorrectposition.

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Question5(12marks)

A58yearoldmanpresentstoyouremergencydepartmentcomplainingofshortnessofbreath.

a. Listtwo(2)abnormalfindingsshowninthisphotograph.(2marks)

• Distendedchestwallveins• Symmetrical-SVCdistribution

b. Statethesignificanceofthesefindings.(1mark)

• SuggestSVCobstruction

c. Listsix(6)likelyunderlyingcausesforthesefindingsinthispatient.(6marks)• Mediastinalmass

o Tumors§ 1˚lung§ Lymphoma§ metastaticlymphadenopathy(testicular)§ teratodermoid§ parathyroid§ thymoma

o aorticaneurysmo retrosternalthyroid

• Nonmass-thrombosis,radiationRx

d. Listthree(3)keyinvestigationsthatyoumayordertoassistconfirmtheunderlyingcause.(3marks)• CXR-(maybeDx)• CTchestwithcontrast• Sputumcytology• TFT• Testiculartumourmarkers• TesticularUS• USupperchest-thrombosis

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Question6(12mark)A35yearoldmanpresentstoyouremergencydepartmentwithapainfulRforearm.HehasahistoryofIVdruguse.

a. Whatisthediagnosis?(1mark)• Inadvertant,intra-arterialdruginjection• “trashhand”

b. Statethree(3)findingsinthisphotographtosupportthisdiagnosis.(3marks)

• Proximalextensiontocubitalfossaregion-freqsiteofIVaccess• Reticularerythematous,purplediscolourationindistributionofradialartery• Sparingofulnaraspectofhand

c. Listfour(4)keyinvestigationsforthispatient.(4marks)

• CK• U+E• VascularUS• Angiography

d. Listfour(4)definitivetreatmentoptionsforthispatient.(4marks)NB:littlesupportorconsensusforanyoptionovertheother Fasciotomyifcompartmentsyndrome(notadefinitiveRxoption)

• IVheparin• IAvasodilators(egGTN)• IAprostacyclin• IAthrombolysis• ReconstructivevascularSx• Amputation

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

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Question7(12marks)A67yearoldmanisbroughtintoyouremergencydepartmentbyhiswifefromhome.Hehasbeenincreasinglyshortofbreathandunsteadyonhisfeetoverthepastweek.

Serumbiochemistry ReferencerangeNa+ 145 mmol/l 134-146K+ 8.0 mmol/l 3.4-5.0Cl- 107 mmol/l 98-106Bicarbonate 5 mmol/l 22-28Urea 63.2 mmol/l 2.5-6.4Creatinine 3.40 mmol/l 0.05-0.1

a. Provideone(1)calculationtohelpyoutointerprettheseresults.(1mark)

Derivedvalue1:

• Aniongap=(145+8)–(5+107)=41&HCO3-is5∴AG(mEq/L)={[Na](mmol/L)+[K](mmol/L)}-{[HCO3]mmol/L+[Cl](mmol/L)}or33ifKleftout

o ReferenceRange:7-17mEq/LOftenK+isleftoutandthenAGref.Rangeis7-13• Ur:CrisokbutAGisbetter

b. Interprettheseresultsinthesettingofthisscenario.Listthree(3)points.(3marks)

• mod→severe,highaniongapmetabolicacidosis• Severe,potentiallylife-threateninghyperkalaemia• MarkedrenalfailurewithlowUr:Cr

c. Listtwo(2)likelydifferentialdiagnosisforthecauseoftheseresults.(2marks)NB: Renalfailurelikelyrenalorpostrenalcause(prerenalunlikelygivenUr:Cr) “hehasnoPHx,nomeds”Multiplepossibilitiesforrenalfailureeg.

• Renal-ATN• AcuteGN• Postrenal-prostatism• Bladder/prostatetumour• Calculi

d. Listthree(3)urgent,keyinvestigationsthatyouwouldorderforthispatient.State1justificationfor

eachchoice.(3marks)• ImmediateECG(signsofhyperkalaemia(&pericarditis))• CXR(causeofSOB,evidenceofpulmonaryoedema,pericardialeffusion)• ABG(assessdegreeofacidosis,ptabilitytoresp.compensate)• Urine(forsediment/spotelectrolytes/microscopy-etiologicclueseg.RBC,casts• UrgentrenalU/s-?obstruction,hydronephrosis,kidneysize(smallsuggestsCRF)&

architecture

Youcouldarguethetestsbelowarenoturgentandnotasgoodchoicesasabove,butlet’snotgetaugmentative.• FBE-evidenceofinfection,normochromic,normocyticanaemiamaysuggestchronic• Commence24urinarycollection-forrenalteam-mayhelpwithDx• Serumalbumin-markerofchronicRF,Dxnephroticsyndrome• Othersasindicated:

o Ck-?rhabdomyolysisascauseo Digoxinlevelo Triglyceridelevel-?nephriticsyndromeo KUB/CTKUB-ifstonesuspected(avoidcontrast)o Renalarteriographyifvascularcauseindicated

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Question8(12marks)

A65yearoldmalepresentsissuccessfullyresuscitatedafterexperiencinganoutofhospitalventricularfibrillationarrest.

a. Whatisyourtemperatureaimforhisongoingcare?(1mark)• 36˚C

b. Providejustificationforthischoice.Statefive(5)pointsinyouranswer.(5marks)

• Currentevidencesupportsstricttemperaturecontrolor“Targetedtemperaturemanagement”

• TTMtrial2013showednobenefitofcoolingto33˚Ccomparedto36˚C• Nodifferenceinmortality• Nodifferenceinneurologicalstatus• Seriousadverseeffectsgreaterinthe33˚Cgroup

CurrentevidencesuggestsTTMaftercardiacarrestimprovesneurologicallyintactsurvival,thoughthemechanismisuncertain.PriortoTTM,theterm‘therapeutichypothermia’wasused—thiswassupersededbyTTMduetoconcernsthathypothermiawas

notanecessarycomponentoftherapyandthishasbeenreinforcedfollowingtherecentpublicationoftheTTMtrialProtocolsvaryfromcentertocenter,andmanyareexpectedtoshiftfromtargetingT33CtoanewtargetofT36Cinthewakeof

theTTMtrialTTM’sMECHANISMOFBENEFIT

Thisiscontroversial,thesearenon-mutuallyexclusivepossibilities:• avoidanceofhyperthermia(decreasedmetabolicdemandandfever-relatedtissueinjury)• reductioninmetabolicdemand(throughpreventionoffever,seizurecontrol,cooling,sedationandneuromuscular

blockade)• improvedoverallcare(focusingthecoordinatedeffortsofanexpertteamwithclosemonitoringandprioritisationof

therapiesonacriticallyillpatient)• reductioninischemic-reperfusioninjury(includingeffectsonexcitotoxicty,neuroinflammation,apoptosis,freeradical

production,seizureactivity,blood-brainbarrierdisruption,bloodvesselleakageandcerebralthermopooling)EVIDENCESummaryTargetedTemperatureManagement(TTM)isaninexpensive,noninvasivetherapythatoffershopeofbenefitforaconditionwith

potentiallydevastatingconsequencesFollowingthepublicationoftworandomisedcontrolledtrialsin2002,bytheBernardetalandtheHACAgroup—anddespite

theirinherentflaws—theuseoftherapeutichypothermiaprotocolstargetingT32-34CbecamewidespreadBernard,etal(2002)foundanAbsoluteRiskReduction(ARR)fordeathorseveredisabilityof23%,numberneededtotreat(NNT)

was4.5• smallpseudo-randomised(alternatedays)trialwithoutallocationconcealment;n=77• cooledtoT33for12hversusstandardcare• norecordofbaselineneurologicalstatuspriortotheevent• norecordofGCSonarrivalinED• goodoutcome:homeorrehabfacilityatdischarge(ratherthanastructuredassessment)• positiveoutcomeoftrialwouldhavebeenlostif1patientingoodoutcomegrouphadabadoutcome

TheHypothermiaAfterCardiacArrest(HACA)Group(2002)foundanARRforunfavourableneurologicaloutcomeof24%,andNNTof4

MCRCT,n=273• 24hourscoolingversususualcare• primaryoutcome:favorableneurologicoutcomewithinsixmonthsaftercardiacarrest(usedgradingsystem)• noactivetemperaturecontrol—usualcaregroupwerenotactuallynormothermic,theytendedtobehyperthermic• trialstoppedearly• only8%ofscreenedEDpatientswereincluded

TheCochraneDatabase’ssystematicreviewin2009suggestedthatforahospitalusingconventionalcoolingmethodswithabaselineeventrateof20%,theNNTforagoodneurologic

outcomewouldbe~10basedonmoderatelevelevidenceHowever,theTTMtrialbyNielsenetal(2013)foundnodifferencebetweentargetedtemperaturemanagementatT33Cversus

T36CfollowingROSCMCRCT,stratifiedaccordingtosite,noallocationconcealment,36ICUsinEuropeandAustralia

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modifiedintention-to-treatanalysisn=939(T33C:473vsT36C:466patientsintheprimaryanalysis)—inclusioncriteria:Age≥18y,OOHCAofpresumedcardiaccause,sustainedROSCfor20minutes,GCS<8aftersustainedROSC—exclusioncriteria:.pregnancy,knownbleedingdiathesis(otherthanmedicallyinducedcoagulopathy,e.g.warfarin),suspected

orconfirmedacuteintracranialbleedingoracutestroke,unwitnessedcardiacarrestwithinitialrhythmasystole,knownlimitationsintherapyandDoNotResuscitate-order,knowndiseasemaking180dayssurvivalunlikely,knownpre-arrestCerebralPerformanceCategory3or4,>4hoursfromROSCtoscreening,SBP<80mmHginspiteoffluidloading/vasopressorand/orinotropicmedication/intraaorticballoonpump,temperatureonadmission<30°C

Intervention:TTMatT33C:cooledmyvariousmeanstotarget<6hours,maintainedT33Cfor36h,thenrewarmedat0.25Cperhour;feveractivelymanageduntilatleast72hoursaftercardiacarrest.

Comparison:TTMatT36C(otherwisesimilartreatmenttotheinterventiongroup)Outcomes:—Primary:mortalityat180days—Secondary:compositeofpoorneurologicfunctionordeath,definedasaCerebralPerformanceCategory(CPC)of3to5anda

scoreof4to6onthemodifiedRankinscale,atoraround180daysResults:—nodifferenceinmortality:50%oftheT33C(235of473patients)haddied,ascomparedwith48%ofthepatientsinthe36°C

group(225of466patients)(hazardratiowithaT33°C,1.06;95%CI0.89-1.28;P=0.51)—nodifferenceinneurologicaloutcomes:54%oftheT33Cgroupversus52%ofthe36Cgroupdiedorhadpoorneurologic

functionaccordingtotheCPC(RR,1.02;95%CI0.88to1.16;P=0.78).UsingthemodifiedRankinscale,thecomparableratewas52%inbothgroups(RR1.01;95%CI0.89to1.14;P=0.87).

—shorterdurationofmechanicalventilationintheT36Cgroup:T33C=0.83versusT33C=0.76mediandaysreceivingmechanicalventilation/daysinICU(P=0.006)

—seriousadverseeffectswerecommonandmarginallyhigher(withborderlinesignificance)intheT33Cgroup(93%)comparedwiththeT36C(90%)(RR1.03;95%CI1.00to1.08;P=0.09)

—higherratesofhypokalemiainT33Cgroup(19%)thantheT36Cgroup(13%)P=0.02)—nodifferencesfoundinsubgroupanalyses:age>65years,presenceofinitialshockablerhythm,timefromcardiacarrestto

ROSC>25min,andpresenceofshockatadmission—nodifferencesinshivering—duringthefirst7daysofhospitalization,life-sustainingtherapywaswithdrawnin247patients(132inthe33°Cgroupand115

inthe36°Cgroup)Commentaryandcriticisms—TTMisamethodologicalmasterpiece!—unlikeBernard2002andHACA2002,notjustVT/VFOOHCAwereincluded(~80%wereVF/VT)—ausefulstandardisedprotocolforneurologicalprognosticationandtreatmentwithdrawalwasused—thestudywaspoweredtodetectaRRRof20%oranARRof~11%,thusthestudywasnotpoweredtodetectasmaller

treatmenteffect(thismaybemorerealisticduetothelower‘separationeffect’betweenT33CandT36C)—lessthan50%ofT33Cpatientshadreachedtargetat6hours,buttherewasgoodseparationbetweenT33CandT36Cgroups—Baselinebalance:higherratesofpreviousMIandIHDintheT33Cgroup,butnodifferenceintheratesofinterventionsfor

theseconditions—thetruepatient-orientatedoutcomethatmattersisneurologicallyintactsurvival,theauthorsdidn’tusethisastheprimary

outcomebecausemortalityisa‘harderendpoint’andlesssubjecttobias—staffcaringforthepatientscouldnotbeblinded;howeverthedoctorswhoperformneurologicalprognosticationanddata

interpretationforthestudywere—TTMdifferstotheBernard2002andHACA2002trials:largerMCRCTwithexcellentmethodology,notlimitedtoVT/VF,control

groupstillreceivedTTM(butatT36C)—patientsinTTMhadshorttimestoCPR(e.g.~1minute),couldT33Cbemorebeneficialinpatientswithmoreanoxicinjury?—isprognosticationoftheT33Cgroupat72htoosoon,could‘latewakers’havebeenmissed?Bottomline:NodifferencefoundbetweentargetedtemperaturemanagementwithatargetofT36CcomparedtoT33CControversiesanduncertaintiesremainregarding:

• patientselection• optimumtargettemperature• timingofinitiationofcooling• durationoftherapy• rateofrewarming• theimpactoffeverinthecontrolgroupsoftheBernardetal,2002andHAC2002studies• inversusout-of-hospital• VT/VFversusnon-VT/VF

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c. TheambulanceACLSprotocolinyourregiondoesnotincludevasopressin.Whatisthecurrentroleofvasopressinin: (6marks)

i. Outofhospitalarrest:• Vasopressinalonecftoadrenaline–showedhighersurvivalinasystolicpatients• Basedon2004welldesignedtripleblindedRCTwithgoodnumberscomparingadralonevs

vasopressinalone• NotacceptedbytheARC(thereforenotinguidelines)• Possiblechangewithnextguidelines

WenzelV,etal.Acomparisonofvasopressinandepinephrineforout-of-hospitalcardiopulmonaryresuscitation.NEnglJMed2004;350:105-113.tripleblindedmulti-centrerandomisedtrialn=1219initialvasopressin(40IU)vsadr(1mg)thenincrementsofepinephrine/adrenaline->ratesofadmissionunchanged->highersurvivaltohospitaladmissionforpatientsresuscitatedwithvasopressinfromasystoleOlasveengen,T.M.,etal(2009)“IntravenousDrugAdministrationDuringOut-of-HospitalCardiacArrest:ARandomizedTrial”JAMA302(20):2222-

2229RCTNorwegian2003-2008n=851ACLSwithIVdrugadministrationvsACLSandnodrugadministrationprimaryoutcome=survivaltohospitaldischargesecondaryoutcomes=1yearsurvival,survivalwithfavourableneurologicaloutcome,hospitaladmissionwithROSC,qualityofCPR(chest

compressionrate,pauses,ventilationrate)inclusioncriteria:>18years,non-traumatic,OHCAexclusioncriteria:cardiacarrestwitnessedbyambulancecrew,resuscitationinitiatedbyphysicians,cardiacarrestinducedbyanaphylaxisor

asthma->increasedshorttermsurvivalinIVdruggroup->nodifferencetosurvivaltohospitaldischarge,qualityofCPRorlongtermsurvivalWeaknesses— 3minofCPRpriortodefibrillationinVF— 10%ofnodrugsgroupreceiveddrugsduringresuscitation— notpoweredcorrectly

ii. Inhospitalarrests(3marks)• NotincurrentACLSguidelineasanoption• Limitedsmalltrials-doesnotseemtohaveabenefitoveradrenaline• Severalreportedanecdotalsurvivorsfromarrestwhoweregivenvasopressinasalastditcheffortwhen

adrenalinehadfailed• Addingvasopressintoadrenalineandsteroidsmayhavesmallmortalityandneurologicalbenefit• BasedonJAMA2013GreekbasedDBRCTgoodnumbers• Mayhaveabenefitinsevereacidosiscfadrenaline

JAMA.2013Jul17;310(3):270-9.doi:10.1001/jama.2013.7832.Vasopressin,steroids,andepinephrineandneurologicallyfavorablesurvivalafterin-hospitalcardiacarrest:arandomizedclinicaltrialIMPORTANCE:Amongpatientswithcardiacarrest,preliminarydatahaveshownimprovedreturnofspontaneouscirculationandsurvivaltohospitaldischargewiththevasopressin-steroids-epinephrine(VSE)combination.OBJECTIVE:Todeterminewhethercombinedvasopressin-epinephrineduringcardiopulmonaryresuscitation(CPR)andcorticosteroidsupplementationduringandafterCPRimprovesurvivaltohospitaldischargewithaCerebralPerformanceCategory(CPC)scoreof1or2invasopressor-requiring,in-hospitalcardiacarrest.DESIGN,SETTING,ANDPARTICIPANTS:Randomized,double-blind,placebo-controlled,parallel-grouptrialperformedfromSeptember1,2008,toOctober1,2010,in3Greektertiarycarecenters(2400beds)with268consecutivepatientswithcardiacarrestrequiringepinephrineaccordingtoresuscitationguidelines(from364patientsassessedforeligibility).INTERVENTIONS:Patientsreceivedeithervasopressin(20IU/CPRcycle)plusepinephrine(1mg/CPRcycle;cycledurationapproximately3minutes)(VSEgroup,n?=?130)orsalineplaceboplusepinephrine(1mg/CPRcycle;cycledurationapproximately3minutes)(controlgroup,n?=?138)forthefirst5CPRcyclesafterrandomization,followedbyadditionalepinephrineifneeded.DuringthefirstCPRcycleafterrandomization,patientsintheVSEgroupreceivedmethylprednisolone(40mg)andpatientsinthecontrolgroupreceivedsalineplacebo.Shockafterresuscitationwastreatedwithstress-dosehydrocortisone(300mgdailyfor7daysmaximumandgradualtaper)(VSEgroup,n?=?76)orsalineplacebo(controlgroup,n?=?73).MAINOUTCOMESANDMEASURES:Returnofspontaneouscirculation(ROSC)for20minutesorlongerandsurvivaltohospitaldischargewithaCPCscoreof1or2.RESULTS:Follow-upwascompletedinallresuscitatedpatients.PatientsintheVSEgroupvspatientsinthecontrolgrouphadhigherprobabilityforROSCof20minutesorlonger(109/130[83.9%]vs91/138[65.9%];oddsratio[OR],2.98;95%CI,1.39-6.40;P?=?.005)andsurvivaltohospitaldischargewithCPCscoreof1or2(18/130[13.9%]vs7/138[5.1%];OR,3.28;95%CI,1.17-9.20;P?=?.02).PatientsintheVSEgroupwithpostresuscitationshockvscorrespondingpatientsinthecontrolgrouphadhigherprobabilityforsurvivaltohospitaldischargewithCPCscoresof1or2(16/76[21.1%]vs6/73[8.2%];OR,3.74;95%CI,1.20-11.62;P?=?.02),improvedhemodynamicsandcentralvenousoxygensaturation,andlessorgandysfunction.Adverseeventratesweresimilarinthe2groups.CONCLUSIONANDRELEVANCE:Amongpatientswithcardiacarrestrequiringvasopressors,combinedvasopressin-epinephrineandmethylprednisoloneduringCPRandstress-dosehydrocortisoneinpostresuscitationshock,comparedwithepinephrine/salineplacebo,resultedinimprovedsurvivaltohospitaldischargewithfavorableneurologicalstatus.

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Question9(18marks)A70yearoldwomanisbroughtintoyouremergencydepartmentbyherson,whoreportsthatshehashad2daysofconfusionwithepisodesofagitationfollowingusingpromethazineforanitchyrash.

a. Otherthanconfusionandagitation,listfour(4)examinationfeaturesthatwouldbeconsistentwithpromethazinetoxicity.(4marks)

Anticholinergic• Central

o drowsiness/comao Visualhallucinationso Behaviouraldisturbanceo Slurredspeecho Seizures

• Peripheralo Tremor,myoclonuso Mydriasiso CVS–Tachycardia,hypertensiono Hyperthermiao Skin-dry,red/flushed(dryskinakeydifferentialfromsympathomimeticcause)o GIT-drymouth,ileus,o GUT-urinaryretention

b. Listfour(4)otherpotentialcausesofasimilartoxidrome(eachtobefromadifferentdrugtypeanda

differenttypetopromethazine).(4marks)Antidepressants TCAAntipsychotics Haloperidol,chlorpromazine,olanzepineAnticonvulsants CarbamazepineAntihypertensives PropranololAntiparkinsoniandrugs BenztropineAntimuscarinicagents AtropineIllicit/Recreational Lesslikelyinthispatient,unlessinadvertentDatura,mushrooms

c. Whatistheroleofdecontaminationinpossiblepromethazineoverdose?(2marks)

• Norole• Charcoalnotindicatedduetoriskofearlydrowsiness

d. Whatistheroleofenhancedeliminationinpossiblepromethazineoverdose?(1mark)

• Notclinicallyuseful-norole

e. Whatistheroleofantidoteuseinpossiblepromethazineoverdose?(1mark)• PhysostigmineinsevereanticholinergicdeliriumnotcontrolledwithBz

f. Listsix(6)featuresonexaminationthatmightraisethepossibilityofelderneglect. (6marks)

• Featuresofneglect–malnutrition,poorhygiene,pressuresores• Featuresofphysicalabuse–bruises,injuries• Familyinteractions-Inappropriateorantagonistic