UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK2–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)9minutesA72yearoldwomanpresentswithtearingchestpainsuggestiveofdissectionofheraorta.

a. Statethree(3)prosfortheutilityofchestXrayinthispresentation.(3marks)NB:FocusPros/consonclinicalrelevance-notcheap/easy(rapidmaybeokbutusuallybetteralternatives)• MayshowfindinghighlysuggestiveofTAD-egdoublelumensign• Mayshowalternativediagnosis(egpneumomediastinum)• Maybeperformedbedside(avoidstransferringunstablepatient)

b. Statethree(3)consfortheutilityofchestXrayinthispresentation.(3marks)

• Poorsensitivity-~60%screeningtestonly,cannotbeusedtoruleoutTAD,highfalse–ve• Poorspecificity–widenedmediastinumonAPorsupine,highfalse+ve• Doesn’tdefineextent/typeofTAD• MaydelayformalIx

c. Listsix(6)ChestXrayfindingsthatsupportthediagnosisofthoracicAorticdissection.(6marks)

NB:although"normal"in~15%-thisdoesnot"supportthediagnosis"• Widenedmediastinum(56-63%)• abnormalaorticcontour(48%)• aorticknuckledoublecalciumsign>5mm(14%)• pleuraleffusion(L>R)• trachealshift• leftapicalcap• deviatedNGT

d. Statesix(6)keyissuesinthemanagementofapatientwithproventhoracicAorticdissection.(6

marks)• Analgesiae.g.titratedIVmorphinewillhelpwithBPcontrol• EstablishRxaims/limitations• Definitivetreatmentisurgenttominimisemorbidityandmortality• Bloodpressurecontrol(endpointsBP100-120mmHgandHR60-80/min)

o BBlockerfirst(e.g.labetolol10mgaliquotsIVq10mins)o vasodilatorifnecessarysubsequentlyegGTN

• Involvingascending/arch-StanfordA-Refercardiothoracics-Surgicalemergency-considerationforSx/endovascularmanagement

• Descending-StanfordB-surgicaldiscussion-usuallymedicalmanagement• Complications:

o hypotensive-urgentsurgicalreview§ (DDx-bloodloss,haemopericardiumwithtamponade,valvedysfunction,L

Ventriculardysfunction)• Avoidpericardiocentesis&inotropes

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

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Question2(13marks)6minutesA4yearoldmalepresentstoEDafterhavinginsertedapeanutintohisnostril.Thechildisextremelydistressedandwillrequirechemicalsedationforremoval.Thechildweighs20kg.

a. Listyourchoiceofpreferredmedication,routeofadministrationanddose/s.(3marks)NB:

• IMpreferable-IVOkbutchildisdistressed,IVwillbemoredistressing&isunnecessary• Aschildisdistressed,needadosethatisgoingtobesedating,notjustanalgesic• Mayspecifyarepeatdosedependingonresponse• Ifrepeatdosenotspecified,dosemustbeadequatetocausesedation• AnynasaladministrationisCI• Ketamine: Lowdose<60withnorepeatspecifiedisnotadequate

Medication(1mark)

Routeofadministration(1mark)

Dose/s(1mark)

Ketamine

IM Initialrange3-7mgacceptable=60-140mgSubsequenttomax10mg/kg(analgesia2-4mg/kgsedation5-10mg/kg)

Midazolam IM 0.1-0.2mg/kg2-5(max)mg(0.1-0.2mg/kgtomax5mg/adult)

b. Otherthansedation,list4possiblecomplicationsofyourpreferredmedicationchoice.(4marks)Ketamine MidazolamVomiting~15%AirwayhypersalivationTransientlayngospasm,stridor(esp.ifURTI)Resp.depression/Transientapnoea/desaturationAgitation/hallucination/cryingNightmaresEmergence(uncommoninchildren)

Resp.depression/Transientapnoea/desaturationHypotensionHyperstimulation

c. Listfive(5)indicationsforENTremovalofthisnasalforeignbodyasopposedtoremovalintheEmergencyDepartment.(5marks)

• Parentalrequest• FailureofEDremoval• Childnotfasted• Delayedpresentation-nasalpassageassociatedwith++Swelling• Significantepistaxisprior• PriornasalsurgeryandhighlodgedFB• Congenitalanatomicalabnormality• Likelytobetechnicallydifficulte.g.posteriorposition• Resourcelimitationse.g.stafforspaceunavailabilityforproceduralsedation

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Question3(11marks)6minutes

a. Statethedefinitionofpriapism.(1mark)• prolongedpenileerection(exacttimedurationisnotuniversallyagreedand∴notrequired)• unrelatedtoongoingsexualstimulation• unrelievedbyejaculation

A35yearoldmalepresentstoEDwithpriapism

b. Listfive(5)likelycausesofpriapisminthisman.(5marks)NB:keepit“likely”foramanthisage

• Lowflow:o Idiopathico Medications:

§ Sidenafil(Viagra)§ Intracavernosumagents(egpapverine)§ AntiHT(CCB,αantagonists)§ Antipsychotics(chlorpromazine/clozapine)§ Antidepressants(SSRI)§ Anticonvulsants(Navalproate)§ Warfarin§ Hormones(testosterone)§ Maxolon§ Omperazole

o Recreationaldrugs(heroin,cocaine)o Leukaemia/Thalassemia/SCAo Malariao Amyloidosis,gouto Highspinallesiono (Spider-blackwidow)

• Highflow:o Trauma

§ fistulaformation§ SCtrauma

c. Listtwo(2)simplestepsthatmayhelptoresolvethepriapisminthispatient.(2marks)• Micturition• Exercise• Icetopically

d. Listtwo(2)medicationsthatmaybeusedtoresolvethepriapisminthispatient.(2marks)

• Oralpseudoephedrine• Intracavernosuminjectionofmetaraminol/phenylephrine• Treatreversiblecause-chemoforleukaemia

e. Stateone(1)keyprocedureforthispatientintheemergencydepartmentiftheabovestepsfail

toresolvethepriapism.(1mark)• AspirationofcorpuscavernosumunderLA(20-30mltomax300mlover15min)

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Question4(12marks)6minutes

An88yearoldfemalepresentsfollowingafall.

a. Statesix(6)abnormalfindingsshowninthisscan.(6marks)• RChronicSDH10x2.5cm-hypodense(>2/52old)• LAonChrSDH11x3cmhyperdenseandhypodense• (Signsofraisedintracranialpressure):

o Midlineshift3-4mmtoRo Lossofgrey/whitematterdifferentiationo Llateralventricleeffacemento Sulcaleffacement

• RExternalventriculardrainintoRlateralventricle

Thepatientisconfirmedtobeahostelresident.Sheisindependentlymobilewithmilddementia.Sheisunabletoprovideanopinionabouthercare.

b. Statesix(6)factorsthatwouldleadyoutopursueactivemanagementforthispatient.(6marks)• Lackofsignificantcomorbidities• Goodpremorbidqualityoflife• Warfarinuse-willneedreversal• ConfirmedHxofphysicalabuse• Advancedcaredirectives-forallcare• MedicalPowerofAttorneyrequest• AdvicefromhospitalMedicalSuperintedant

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Question5(14marks)6minutes

A38yearoldmalecollapseswhileexercising.Hespontaneouslyrecoversduringtransportbyambulance.HisECGisshown.

a. Statethree(3)abnormalitiesshownonthisECG.(3marks)• Rate-Ventricular75-130,atrialrate300bpm• Rhythm-Atrialflutterwithvariableblock2:1,3:1• TwaveflatteningV5-V6

b. Stateyourdisposition.(2marks)• Monitoredbed(1)undercardiology(1)

c. Statefour(4)pointsofjustificationforyourchosendisposition.(4marks)• Syncopesuggestshaemodynamicallysignificantarrhythmia• UnlessnoncardiacprecipitantforAflutterispresent• Rate/rhythmcontrol• FacilitatesemiurgentECHOpriortodischarge(probably)• +/-angio

ThepatientwishestodischargeagainstadvicesoonaftertheECGistaken.

d. Listfive(5)questionsthatmustbeansweredforthispatienttobelegallyallowedtodischargehimselfagainstmedicaladvice.(5marks)NB:adutyofcareexists-so“Isthereadutyofcare?”isnotananswer

• Isassessmentcomplete?• Whydoeshewanttoleave?• Isthepatientcapable,competent(Capacityassessmentseewk1&Dunnpage273-4)ofrefusingtreatment?• Cansomeoneelselegallydetermineconsent?• WhatistheriskofDAMA?• Whatistheriskofthepatientofrestraint?

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Question6(12marks)6minutes

Apreviouslywell48yearoldfemalepresentstoEDwithacuteurinaryretentionandlossofperinealsensation.

a. Listthree(3)likelydifferentialdiagnoses.Foreachdiagnosis,statehowyouwouldconfirmeachdiagnosis.(6marks)

Diagnosis(3marks)

Methodofconfirmationofdiagnosis(3marks)

Spinalcordinjury-haematoma

• CTSpine• MRIspinalcord

Spinalcordinfection• epiduralabscess• transversemyelitis• discitis

• CTSpine• MRIspinalcord

Cancer• Epiduralmetastasis• Primarypelvictumour

• CTSpine

Systemicdisease• MS• GBS

• MRIB&Spine• Clinical• LPforGBS

Spinalarterythrombosis

• CTSpine

Lesslikely(givenpreviouslywell):• Progressiveneurologicaldisease• Diabeticneuropathy

b. Listsix(6)keyfeaturesthatyouwouldseekonhistory.(6marks)

• HOPCo Backpain-progressionofsymptomso Trauma-mechanismo Infectivesymptomso IVDUo Embolicsymptomso MSsymptoms-esp.eyepaino Recentspinalanaesthesia-egdelivery

• FHxo MS/otherdiseasesaslisted

• Smoking• Systems

o Symptomsofmetastasis

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Question7(11marks)6minutes

A29yearoldfemaleisbroughtinbyafriendafterbeingfoundinanagitatedstate.Sherefusesallassessmentexceptforanarterialbloodgasandelectrolytesonroomairasdisplayedbelow.

a. Providetwo(2)calculationstohelpyoutointerprettheseresults.(2marks)

Derivedvalue1:AG-AG=9.5=NormalaniongapmetabolicacidosisDerivedvalue2:ExpectedpCO2=36=respiratoryalkalosisSimplemetabolicacidosis:PCO2= 1.5xHCO3-+8

LowerlimitofcompensationPCO2=10 Or PCO2=lasttwonumbersofthepHbetween7.4and7.1

§ combinationof↓HCO3&↓pCO2occursinmetabolicacidosis&respiratoryalkalosisifonlyonedisorderispresentitisusuallyeasytodeterminewhichisoccurring→Hxusuallystronglysuggestsdisorder→NetpHchangeusuallyindicatesthedisorderifonlysingle1°disorder→↑aniongapor↑Cl-definethe2majorcausesofmetabolicacidosis (AG>20highlysuggestive,>30definiteformetabolicacidosis)

§ Commonsituationis↓HCO3&↓pCO2,butpCO2is>thanpredictedbyexpectedcompensation∴metabolicacidosisandassociatedrespiratoryacidosis2°tohypoventilationeg.severeDKA,severesepsis,coexistingrespiratorydisease,arrest,collapse&ICpathology

Herfriendconfirmsthatshehasbeendepressedlatelyandhasaccesstoherparentsandgrandparentsmedications.Shewaswitnessedtoingestaboxoftablets4hoursago.b. Assumingasoleingestant,statethemostlikelytoxicagentinvolved?(1mark)

• Digoxintoxicity-byfarmostlikely• Possible:

o SpironolactoneODo AspirinOD(hypokalaemianothyperkalaemia)

c. What is your risk assessment for this patient based on these blood results? Provide one (1)justificationforyourassessment.(2marks)

• Riskassessment:Potentiallylife-threatening• Justification:severehyperkalaemiaassociatedwithsignificantdigtoxicity(K>5.5100%deathwithouturgentintervention)

d. Listfive(5)medicationsthatyoumayusetostabilisethispatient(nottoincludemedicationsforrapidsequenceinduction).Includestartingdosesforeachmedication.(5marks)

• Digibind(5ifHDstable-10ifHDunstable-20ampulesifcardiacarrest)• NAHCO3100ml8.4%IVbolus• Insulin10U&50ml50%Dextrose• AtropineifAVblock-600mcgIVtomax1.8mguntilHR>60• LignocaineifVentriculararrhythmias-100mgIVover2/60

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Question8(12marks)6minutes

a. Statefour(4)keyfeaturesoftheAustralasiantriagescale.(4marks)

• Requiredbecausemostdepartmentsdonothavethecapacitytotreatallpatientsimmediately

• AllpatientsmustbetriagedonarrivalbytrainedRN/MO• Triagedtooneof5categories• Triagecategoriesbasedontimetomedicalreview• Guidelinesexisttoallowstandardisationoftriagingbetweenindividuals• Categoriesareameasurementofurgency• Triageprocesscontinuesandretriagemayoccuratanystageinresponsetochangein

illness• Waitingtimesshouldbemonitoredcontinuouslysothatevennonurgentshouldnotwait>

2/24

b. Statefour(4)problemsassociatedwiththeprocessoftriage,ingeneral.(4marks)• Inter-observervariability• Institutionvariability

o SmallerEDsallocateahigherprioritypersameacuity• Regionalvariability

o FundingaccordingtoATS1-3waitingtimesonlyhaveincreased4-5• Minimalinformationoftenavailable• Lackofprivacyforassessment• Timeload

o Multiplepatientso Lackoftimeforassessmento Documentationrequirementso Delaytotreatment

• Conflictbetweenptsandstaffperceptionofurgency• Lackofevidencetosupportimpactonpatientoutcomes• Fundingallocationbasedontriageallocation

c. Statefour(4)problemsassociatedwiththeprocessoftriageofthepoisonedpatient.(4marks)

• Minimalinformationmaybeavailablefrompsychiatricpt• Lackofprivacyforassessment/maybereluctanttodivulgedetails• PresentationsoonafterpotentiallylethalODmayappearreasonablywell• Appropriatetriagescoreisverydifficultwithoutknowledgeoftoxicopharmacologyof

agentingested• KnowledgetoodetailedfortriageRN-needmedicalinput

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au April2017

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Question9(18marks)9minutesA48yearoldfemalepresentstoEDwithshortnessofbreath.Thisxrayistakensoonafterarrival.

i) Statesix(6)abnormalfindingsonthisCXR. (6marks)

• LLLopacification• DecreasedvolumeLlung/raisedLhemidiaphragm• Asymmetricalbreastshadows• Laxillaryclips• Lhilarregionsclips• RIJCVC/portocathSVC

Thepatienthasatemperatureof39°C.

ii) Listfive(5)factorsthatwoulddetermineyourantibioticchoice. (5marks) • Patient:

o Neutropaenia/immunocompromiseo Allergies

• Diseasefactors:o Previousculturesandsensitivitieso Localpathogens&resistancepatternso Communityversushospitalacquired(mayinferHAgivenactiveCVCandthereforeactiveRx)o Severitydiseasee.g.POvsIV

• Hospitalfactors:o Localprotocolsandantibioticguidelines

Thepatientrequeststohavea“DoNotResuscitate”order.iii) Statesix(6)issuesinrelationtothisrequest.(6marks)

• IdeallyshouldbeinconjunctionwithRxteam• Ptautonomy• PriorEndofLifeChoicedocumentation• Ptcompetenceingeneral,butespgivenintercurrentillness?competency• Patientperceptionandunderstanding• Taketimeforconsideration• Confidentiality• Confirmfactsofillnessi.e.potentiallyreversiblecondition• Currentdiseasesatee.g.mets,longtermprognosis,diseaseburden• Documentrequest