Question 1 (18 marks) - LITFL · § LP → 90% < 10 cells/ml, mainly T lymphocytes, ↑ IgG,...

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WEEK15–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)

a. CompletethetabletodistinguishbetweentheclinicalfeaturesofGuillain-BarréSyndromeandMultipleSclerosis.(4marks)

History Guillain-BarréSyndrome MultiplesclerosisAgeatonset Typicalonset:20-40yroldOnset Insidious

Postinfection/Sx/Immunisation/malignancyEpisodic,relapsing,remitting

Distribution AscendingmotorparalysisGlove&stockingloss

Random,eyesoften1st

Limbpain Passivemovement/calfpaincommon Electricshocksensationsinlegs,worsewithneckflexion

Visualdisturbance Opthalmoplegiarare OpticneuritisPainfuleyemovementsVA/fielddefects

CerebralFx IntellectualdemiseSeizures

Naturalcourse >90%recovery Stabilise&improveProgressive

Sex Female:male2:1b. CompletethetabletodistinguishbetweentheexaminationfeaturesofGuillain-BarréSyndromeandMultiple

Sclerosis.(4marks)Examination Guillain-BarréSyndrome Multiplesclerosis

CN 50%facialnorbulbar Common,espeyesION,RAPDCerebellarsigns Rare MaybepresentGait weakness SpasticTone ↓ ↑,clonusReflexes ↓/flaccid(LMN) ↑(UMN)Autonomic Common Rare-sensory-BladderdysfunctionRespiratorycompromise ↓FEV1

RespiratorysupportmayberequiredRare

c. Listthetwo(2)investigationsofchoicetoassistwiththediagnosisofMultipleSclerosis.Statetwo(2)diagnostic

findingsthataresupportiveofMultipleSclerosisforeachinvestigation.(6marks)Investigationofchoice1: CSFexaminationSupportivefindings:

• (90%)<10cells/ml-Tlymphocytepredominance• Normalprotein• Iggy(↑in80%)

o Oligoclonalbands(85-90%ofclinicalMS)Investigationofchoice2: MRIBrainSupportivefindings:

• Subcorticalandperiventricularplaques(50%)• Enhancementindicatesactivity/resolveswithremission

d. AssumingthediagnosisofGuillain-BarréSyndrome,whichdrugmustnotbegivenifintubationisrequired?(2

marks)• Sux • Precipitationoflifethreateninghyperkalaemia(absolutelycontraindicatedinpatientswithGBS.There

havebeenanumberofcasereportsofseverehyperkalaemia,lifethreateningarrhythmias,andcardiacarrestafteritsadministrationinGBS)

e. Listthetwo(2)optionsfortreatmentofGuillain-BarréSyndrome.(2marks)• IVImmunoglobulin• Plasmaphoresis(usuallynotbothtogether,it’saneither/or)

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

GuillainBarreSyndrome§ Commonestcauseofrapidonsetparalysisinpreviouslyhealthyperson.§ Bothsexes.Allages§ Acutepolyneuropathy1-4weekspost:

§ 70%postviralURTI/gastro§ Postoperative§ Postimmunisation§ Intercurrentmalignancy

§ Pathology→neuronitiswithmyelindestructionand∴Walleriandegenerationofneurones

ClinicalfeaturesSensory§ Initialparaesthesiainhandsandfeet→minorgloveandstockingloss(sensoryneuropathyisusuallyminimal)§ Posteriorcolumnvibration/proprioception>spinothalamicMotor§ Progressiveascendingmotorweaknessaffecting>1limb→distalmmweaknesswithoutatrophy(25%prox>distal)§ Areflexia/markedhyporeflexia§ Limbpainonpassivemovement/calfpain§ CNin~50%→usuallyfacialnnorbulbar(allexceptI,II,VIII,extraocularmmrarelyinvolved) -MillerFischervarianthaspredominantCNinvolvementOther§ Nofever/neckstiffness,normalmentalstate§ Autonomicdysfunction -Badprognosticindicator -Verysensitivetocardiacdrugs→mayarrestonintubation -Ileus,retention,assoc.SIADH

Investigations Dx -CSFprotein↑in90% >0.4g/l -CSFcountnormal

-FET→monitorprogress Tx -ABG -RFT -Excludeothercauses

Management§ CVS,Respsupport§ SUXAMETHONIUMASSOCIATEDWITHSUDDENDEATH§ Nutrition→enteral,parenteral§ Plasmaphoresis -Superiortosupportivealone -Bestifcommenced<7daysafteronset -↑speedofrecovery -Nochangetoultimatemortality§ ImmunoglobulinRx -ProbablyasusefulasplamaphoresisPrognosis§ Good→mostfullrecovery§ Worseprognosisif: -autonomicinvolvement

-deficitnot↓in3/52§ 2%mortality→resp.failure§ 10%majorresidualdeficitDDxofacuteascendingmotorparalysis§ Rhabdomyolysis§ Tick/snakebite§ Diphtheria/polio/botulism§ PANDDXautonomicneuropathy

§ DM§ ETOH§ Amyloid

Multiplesclerosis§ Commonestchronicneurologicalcondition§ Onset30-40’s,60%F§ 20%asymptomaticthroughlife§ HigherincidenceinTas,lowerasgonorthinAus§ Pathology→ Extensivewhitematterplaques,lossofoligodendrocytes,axonalsparing Conductiondisturbedbyfever,stress,electrolyteimbalance(lossofsuppressorTcellsb4attacks)

Clinicalfeatures

§ Episodicattacksoffocalneurologicaldeficit→sensory,motororsphincter§ Predilectionforspinalcord,brain,opticnerves§ Over2-14/7thenremission§ ~½presentassinglesignorsymptom§ Common→limbweakness,opticneuritis(painwiteyemovements,↓VA),sensorysymptoms,diplopia

1. Spinalcord→ commonestmanifestation§ limbweaknessin40%,UMNsigns(spasticgait,↑tone,clonus,↑reflexes),postcolumnloss§ painfulspasms§ bladderdysfunction,constipation§ Lhermittessign→painfulelectricshocksdownlegs↑byneckflexion

2. Opticneuritis→40%atsomestage,presentingsymptomin20%Significantpainwitheyemovementispresentinnearlyeverycaseofdemyelinatingopticneuropathy

§ VAoverdays,centralscotoma,usuallyunilateral§ disturbedcolourperceptionearlysign§ visualfielddefects§ painoneyemovement§ Ex:50%papillitisonfundoscopy,relativeafferentpupilliarydefect§ 40%goontoMS§ 1/3completelyrecover,partially,notatall§ Uhthoff’sphenomenon→↓visiondtexercise,hotmeal/bath

3. Brainstem→ common§ Diplopia,III,IV,VICNlesions§ InternuclearopthalmoplegiaalmostDxofMSorSLE AbnoofMLF→ipsilateraladductioninability,contralaterallat.gazenystagmus§ Bell’spalsy§ Vestibularneuronitis→vertigo,vomiting,nystagmus§ Cerebellarsigns

4. Cerebral→ Intellectualdemise§ Depression§ Seizures~5%§ Rare→dysphasia,hemiparesis,homonymoushemianopia

Diagnosis§ Involvementofdifferentpartsofnervoussystem,2separateoccasions,lasting>24/24orslowprogressionover6/12§ Requires2anatomicallyseparatelesions§ Delayedvisual/auditory/somatosensoryevokedpotentials§ LP→ 90%<10cells/ml,mainlyTlymphocytes,↑IgG,proteinnormal§ MRI→detectsdemyelinatedareas,subcorticalandperiventricularplaquesvisualisedin50% Enhancementindicatesactivityofdisease

DDxEye Retinala/vocclusion Opticnerveglioma MethanolingestionSCdisease Cxspondylosis Subacutedegeneration

Hereditaryataxias SCcompressionCerbral HIV

PosteriorfossaSOL SLE Sarcoid

Mx

§ Acute→highdosemethylpred,ACTH80U,PNL§ Preventrelapses→Azathioprine,cylophosphamide,interferon,plasmaphoresis§ Symptomatic→baclofenforspasms,carbamazepineforpain,urinarycatheter,boweltraining

Opticneuritis

§ Mono-ocularvisionchanges,especiallyinayoungfemaleshouldpromptyoutothinkingaboutthiscondition.§ Opticneuritis(decreasedvisualacuity,relativeafferentpupillaryafferentdefect)caneasilybemistakenforpapilledema

(visualacuityandpupillaryreflexesarenormal)§ Makingthediagnosiscanbedifficultinthatthemajorityofpatientsmayactuallyhaveanormalfundoscopicexambutgivea

classichistoryfor"retrobulbarneuritis"(visionchangesandpainespeciallywitheyemovement).§ Theclinicalpresentationofdemyelinatingopticneuropathyvaries.§ PatientsfrequentlypresenttotheEDwithanacutelossofvision.§ ThenaturalhistoryofMS-relatedvisionlossisrapidlyprogressiveacuitylossforaperiodof10days,whichthen

stabilisesandimproves.§ Additionalocularsignsincludeeyepain,tendernessoftheglobe,dyschromatopsia,decreasedbrightnesssense,decreased

colourperception,arelativeafferentpupillarydefect,assortedvisualfielddefects(altitudinalandcentral/cecocentral),phosphenesuponeyemovementandopticdiscswellingwithorwithoutvitreouscells.Often,theopticnerveisnormalinappearanceandthedysfunctionisconsideredretrobulbar.

§ Demyelinatingopticneuropathycandamagethefibersinboththevisualandpupillarypathways.Thisdamageinterruptsnerveimpulseswithinthepathways,producingdecreasedvisionaswellasanafferentpupillarydefect.

§ Systemicsignsandsymptomsmayincludeheadache,nausea,Uhtoff’ssign(decreasedvisionwithorwithoutlimbweakness

followingexposuretoincreasedtemperaturesi.e.,abathorexercise),Romberg’ssign(patientfallswhentheyclosetheireyes),Pulfrich’sstereophenomenon(beerbarrelappearancetotheenvironment)andfever.

§ Asrecordedinthethree-yearfollow-upofpatientsRxwithintravenousmethylprednisolonefollowedbyoralcorticosteroid

regimensreducedthetwo-yearrateofdevelopmentofclinicalMS,particularlyinpatientswithsignalabnormalitiesconsistentwithdemyelinationonMRIofthebrainatthetimeofstudyentry.Serioussideeffectsofglucocorticoidtherapyareinfrequent.Therefore,outpatientadministrationofhigh-doseintravenousglucocorticoidsmayberecommended.

ClinicalPearls

• AnumberofothertypesofdemyelinatingdisordershavebeenassociatedwithON.Theyare: acutetransversemyelitis

Guillain-BarrésyndromeDevic’sneuromyelitisopticalCharcot-Marie-Toothsyndromemultifocaldemyelinatingneuropathyacutedisseminatedencephalomyelitis.

• Diseasessuchassyphilis,toxoplasmosis,histoplasmosis,tuberculosis,hepatitis,rubella,humanimmunodeficiencyvirus(HIV),Lymeborreliosis,familialMediterraneanfever,Epstein-Barrvirus,herpeszosterophthalmicus,paranasalsinusdisorder,sarcoidosis,systemiclupuserythematosus,Bechet’sdisease,anddiabetesmaycauseopticneuropathyandshouldbeconsideredbeforeprematurelydiagnosingdemyelinatingopticneuropathy.

• Incasesofopticneuropathypresumablysecondarytodemyelinatingdisease,MRIcanassistinsystemicdiagnosisbyidentifyingbotholdandacutedemyelinatingplaqueswithinperiventricularwhitematter.

• Significantpainwitheyemovementispresentinnearlyeverycaseofdemyelinatingopticneuropathy.• Asthevisualdysfunctionisduetoautoimmunedestructionofmyelinandnotdirectinflammationoftheopticnerve

tissue,thisdiseaseentityisbesttermeddemyelinatingopticneuropathy.

Papilloedema

Optic neuritis

Question2(11marks)

A35yearoldmanisbroughtintoyouremergencydepartmentafteranisolatedinjurytotheleftanklesustainedinamotorcycleaccident.Hisobsare:BP160/50mmHgsupineHR110/minGCS15

a. State(4)featuresshownonthisxraythatsuggestasevereinjury.(4marks) • Complete#throughtheneckoftalus• Severecomminutionoftalus• Separationofthemajorfragments>1cm• MarkedanteriordisplacementofdistalfragmentNB:notdislocation/subluxationasanklejointisintact

Heisdeliveredbyambulanceandhasreceivedonlypenthraneenroute.Hedoesnothaveintravenousaccessonarrival.Heisextremelydistressedwithpain.Helastate2hoursago.Hisweightis70kg.

b. Listseven(7)analgesicoptionsforthispatientwhileheisintheemergencydepartment.Includedosesandrouteswhereapplicable.Includeinitialdosesandroutewhereappropriate.(7marks)• Initialoptions:

§ IMketamine3-5mg/kg§ INfentanyl1mcg/kg§ N20

• IVmorphine-5-10mg• Sedationforreduction:

§ IVketamine1-1.5mg/kg§ IVmidazolam3-5mg

• Reduction/immobilisation• Elevation• Ankleblock10-20mlx0.5%plainbupivacaine• PCA• Oraloxycodone/paracetamol

Question3(12marks)A65yearoldfemale,non-Englishspeaking,Italianladypresentswithabout1cupofhaemoptysis.Youare

unabletoobtainanymedicalhistory.Herobservationsare:BP135/65mmHgHR80/minGCS15a. Listfour(4)likelydifferentialdiagnosesforthispresentation.(4marks)• TB• PE• Pneumonia-severewithinfarction• LungCa-primary/secondary• Pulmonaryabscess• Coagulopathy/overanticoagulation• Thrombocytopaenia• Pulmonarycontusion• InhaledFB

b. OtherthanaCXR,listthree(3)keyinvestigationsthatyouwouldconsiderorderinginthe

emergencydepartment.(3marks)NB:listonly-noqualificationneeded

• INR• Sputum-AFB,MCS• CTChest• CTPA • ECG,FBE,UE,LFT,QuanteferonGold,ECHO

AChestXrayshowsunilateralchanges.Sheexperiencesalargevolumehaemoptysis(estimatedbloodloss500ml).

c. Listfive(5)keystepsinthetreatmentofthispatientoverthenext30minutes.(6marks)NB:500mlismassive/lifethreateninghaemoptysis• Communication-Interpreter-obtainfocussedHx/explaintopt• Nursewithaffectedsidedown-Preserveunaffectedlung• Ventilationsupport-Mainstemintubationorcombitube/duallumentubetononaffected

sideonly(anaestheticassistance)• Circulation-Volumereplacement-blood-massivetransfusionifindicated• Reverseanticoagulation-FFP/VitK/Prothrombinex/Tranaxemicacid• Rxunderlyingconditions-PneumoniaIVabs/PE-anticoagulation• Isolation-IfTbexpectedNB:ReferinterventionalXR-Ifbleedingpersistswillprobablybeafter30min

Question4(17marks)A64yearoldmanisbeingevaluatedinyouremergencydepartmentafteranepisodeofchestpainwhichhasnowresolved.Heisgivenaspirinonlyenroutetohospital.2010/1/6.Hisobservationsare:BP140/85mmHgRR20/minO2saturation97%roomair

a. Statefour(4)abnormalfindingsshowninthisECG. (4marks) • Bradycardia~48bpm• Mobitztype1(Wenchebach)2nddegreeHB• STE1mmII,V2-V6• BiphasicTWIIIVi

b. Listfour(4)likelycausesforthesefindings.(4marks)

• Ischaemia• Drugs--vechronotropes(BB,CCB,Digoxin)-therapeutic• Drugs-ODegsameasabove• Cardiomyopathy• Myocarditis

Thepatientbecomessuddenlyunwell.He is lightheadedwithnochestpain. HisBP is70/50mmHg.He isgivena500mlfluidboluswithnoimprovement.

c. Statefive(5)abnormalfindingsshowninthisECG.(5marks)• Rate25-30• CHB• Ventricular/IdioventricularescapeorQRSprolongation• RAD• TWIII,III,V1-V3

(ForQwavestobesignificanttheyneedtobe: >40msec&>2mmdeep&>25%depthofQRS)

d. List in order of escalation, your choice of drug treatment for this patient. Specify dose and route. (4marks)

Drugtreatment Dose1stline Isoprenalineor

AdrenalineBolus20-40mcgIVFollowedbyinfusion0.5-20mcg/min

2ndline Atropine 300mcg-600mcgIV(rarelyeffective)

Question5(14marks)

Aseriesofthree(3)Xraysfromthree(3)differentpatientsareshowninthepropsbooklet

a. ForXray1,statewheretheforeignbodylies.(1mark)

• Loweroesophagusatthegastro-oesophagusjunction. b. ForXray1,listtwo(2)optionsforthenature/compositionoftheforeignbody.(2marks)

• Coin• Roundmetalobject

c. Listtwo(2)factorsthatwouldmandateurgentremovaloftheforeignbody.(2marks)• Excessivesymptoms

o Unabletoswallowo Severepain

• Complicationso Haematemesiso Featuresofperforation

d. ForXray2,wheretheforeignbodylies.(1mark)

• Oesophagus-upper e. ForXray2,whatisthenature/compositionoftheforeignbody?(1mark)

• Buttonbattery f. ForXray2,stateyourdisposition.Providetwo(2)pointsofjustificationforthischoice.(2marks)

• Disposition:Theatre-AdmitGastro/ENT• Justification: Immediateremovalrequired(MANDATORY)(<2/24)

Extensivesurroundingtissuedamagecommences<30min Toolargetoallowwaitandseeifpassageoccursspontaneously

g. ForXray3,wheredoestheforeignbodylie?(1mark)• Upperoesophagus

h. ForXray3,stateyourdisposition.Providetwo(2)pointsofjustificationforthischoice.(3marks)Disposition:AdmitGastro/ENT

Justification: Toolargetopassspontaneously Timingofremovaldependsonsymptoms

Question6(12marks)A45yearoldmanwithtype1diabetesmellitusisbroughtinbyambulancewithanalteredconsciousstate.Hisobservationsare:BP90/70mmHgHR120bpmTemperature36.8 °COxygensaturation97%on8LbyHudsonmaskGCS12E4,V3,M5

a. Providethree(3)calculationstohelpyoutointerprettheseresults.(3marks)

1. CorrectedNa(NeedtocorrectNapriortoAGcalculation)• TrueNa= measuredNa+ + glucose-10/3

Or measuredNa+ + glucose-7/3.5 Or measuredNa+ + glucose/4

2. AnionGap=21∴↑3. Deltagap∆ratio:~1.7∴PureHAGMA 4. Others:

o ExpectedCO2o A-agradient274-247=27∴normalforageo SeOsmo

b. Provideaunifyingexplanationforthisclinicalpicturebasedontheseresults.(3marks)

• HAGMetabolicacidosis-LikelyDKA• 1°respiratoryacidosis-Likelyhypoventilation• Renalimpairment-slightlyincreasedUr:Crlikelypartlyprerenalfromdehydration

c. Complete the following table demonstrating three (3) key specific treatment tasks in the first 2 hours of the

emergencydepartmentstay.Statehowyouwouldachieveeachofthesetasks.

Keytreatmenttask Howwillyouachievethetask?

1 Establish U/O/ correcthypovolaemia

Fluid1LNSStat~250ml/hrfornext4/24MonitorU/OwithFBC(avoidIDC)CVPmonitoring

2 Correcthypoglycaemia FluidsInsulin0.1U/kg/hr(max15U/hr)Followlocalprotocol3-5U/hr

Kbalance ReplaceKasglucosefallsandKfalls Airwayprotection Carefulobservationgivenalteredconsciousstate Treatprecipitant EgSepsis

DeltaratioThisDeltaRatioissometimesusefulintheassessmentofmetabolicacidosis.Asthisconceptisrelatedtotheaniongap(AG)andbuffering,itwillbediscussedherebeforeadiscussionofmetabolicacidosis.TheDeltaRatioisdefinedas:

Deltaratio=(IncreaseinAnionGap/Decreaseinbicarbonate)Howisthisuseful?Inordertounderstandthis,considerthefollowing:Ifonemoleculeofmetabolicacid(HA)isaddedtotheECFanddissociates,theoneH+releasedwillreactwithonemoleculeofHCO3

-toproduceCO2andH2O.Thisistheprocessofbuffering.TheneteffectwillbeanincreaseinunmeasuredanionsbytheoneacidanionA-(ieaniongapincreasesbyone)andadecreaseinthebicarbonatebyone.Now,ifalltheaciddissociatedintheECFandallthebufferingwasbybicarbonate,thentheincreaseintheAGshouldbeequaltothedecreaseinbicarbonatesotheratiobetweenthesetwochanges(whichwecallthedeltaratio)shouldbeequaltoone.Thedeltaratioquantifiestherelationshipbetweenthechangesinthesetwoquantities.ExampleIftheAGwassay26mmols/l(anincreaseof14fromtheaveragevalueof12),itmightbeexpectedthattheHCO3

-wouldfallbythesameamountfromitsusualvalue(ie24minus14=10mmols/l).IftheactualHCO3

-valuewasdifferentfromthisitwouldbeindirectevidenceofthepresenceofcertainotheracid-basedisorders(seeGuidelinesbelow).ProblemAproblemthough:theaboveassumptionsaboutallbufferingoccurringintheECFandbeingtotallybybicarbonatearenotcorrect.Fiftytosixtypercentofthebufferingforametabolicacidosisoccursintracellularly.ThisamountofH+fromthemetabolicacid(HA)doesnotreactwithextracellularHCO3

-sotheextracellular[HCO3-]willnotfallasfarasoriginallypredicted.Theacidanion(ieA-)howeverischargedandtendsto

stayextracellularlysotheincreaseintheaniongapintheplasmawilltendtobeasmuchaspredicted.Overall,thissignificantintracellularbufferingwithextracellularretentionoftheunmeasuredacidanionwillcausethevalueofthedeltaratiotobegreaterthanoneinahighAGmetabolicacidosis.Caution:Inaccuraciescanoccurforseveralreasons,forexample:• Calculationrequiresmeasurementof4electrolytes,eachwithameasurementerror• Changesareassessedagainst'standard'normalvaluesforbothaniongapandbicarbonateconcentration.Sometimestheseerrorscombinetoproducequiteanincorrectvaluefortheratio.Asanexample,patientswithhypoalbuminaemiahavealower'normal'valueforaniongapsousingthestandardvalueof12tocompareagainstmustleadtoanerror.Donotoverinterpretyourresultandlookforsupportiveevidenceespeciallyifthediagnosisisunexpected.GuidelinesforUseoftheDeltaRatioSomegeneralguidelinesforuseofthedeltaratiowhenassessingmetabolicacid-basedisordersinprovidedinthetablebelow.OverallAdvice:Beverywaryofover-interpretation-Alwayscheckforotherevidencetosupportthediagnosisasanunexpectedvaluewithoutanyotherevidenceshouldalwaysbetreatedwithgreatcaution.

DeltaRatio AssessmentGuideline

<0.4 Hyperchloraemicnormalaniongapacidosis

0.4-0.8 ConsidercombinedhighAG&normalAGacidosisBUTnotethattheratioisoften<1inacidosisassociatedwithrenalfailure

1to2 Usualforuncomplicatedhigh-AGacidosisLacticacidosis:averagevalue1.6DKAmorelikelytohavearatiocloserto1duetourineketoneloss(espifpatientnotdehydrated)

>2 Suggestsapre-existingelevatedHCO3levelsoconsider:• aconcurrentmetabolicalkalosis,or• apre-existingcompensatedrespiratoryacidosis

Warning:Beverywaryofover-interpretation-Alwayscheckforotherevidencetosupportthediagnosisasanunexpectedvaluewithoutanyotherevidenceshouldalwaysbetreatedwithgreatcaution.AhighratioAhighdeltaratiocanoccurinthesituationwherethepatienthadquiteanelevatedbicarbonatevalueattheonsetofthemetabolicacidosis.Suchanelevatedlevelcouldbeduetoapre-existingmetabolicalkalosis,ortocompensationforapre-existingrespiratoryacidosis(iecompensatedchronicrespiratoryacidosis).Withonsetofametabolicacidosis,usingthe'standard'valueof24mmol/lasthereferencevalueforcomparisonwhendeterminingthe'decreaseinbicarbonate'willresultinanoddresult.AlowratioAlowratiooccurswithhyperchloraemic(ornormalaniongap)acidosis.Thereasonhereisthattheacidinvolvediseffectivelyhydrochloricacid(HCl)andtheriseinplasma[chloride]isaccountedforinthecalculationofaniongap(iechlorideisa'measuredanion').Theresultisthatthe'riseinaniongap'(thenumeratorinthedeltarationcalculation)doesnotoccurbutthe'decreaseinbicarbonate'(thedenominator)doesriseinnumericalvalue.Thenetofofboththesechangesthenistocauseamarkeddropindeltaratio,commonlyto<0.4LacticacidosisInlacticacidosis,theaveragevalueofthedeltaratioinpatientshasbeenfoundtobeis1.6duetointracellularbufferingwithextracellularretentionoftheanion.Asageneralrule,inuncomplicatedlacticacidosis,theriseintheAGshouldalwaysexceedthefallinbicarbonatelevel.DiabeticketoacidosisThesituationwithapurediabeticketoacidosisisaspecialcaseastheurinarylossofketonesdecreasestheaniongapandthisreturnsthedeltaratiodownwardstowardsone.Afurthercomplicationisthatthesepatientsareoftenfluidresuscitatedwith'normalsaline'solutionwhichresultsinaincreaseinplasmachlorideandadecreaseinaniongapanddevelopmentofa'hyperchloraemicnormalaniongapacidosis'superimposedontheketoacidosis.Theresultisafurtherdropinthedeltaratio.

Question7(12marks)

A65yearoldmanpresentswithalefthandinjury.

a. Listtwo(2)factorsthatarisefromthisimage,thatwouldsuggestapoorprognosisforsuccessful

reimplantation.(2marks)• Site-throughmiddlephalanyxorDIP• Tendonavulsion• Macerationofedges• (Paletiporavulsedpartsnotstoredappropriatelyatpresent-clutchingstraws)

b. Listsix(6)historicalfactorsthatwouldsuggestapoorprognosisforsuccessfulreimplantation.(6marks) • Timeofinjury/delaytorepairWarmischaemia>6badandcoldischaemiatime>12bad• Age• SmokingHx Mostimportant• PVD • Diabetes• Steroiduse• Delay/incorrectcoolingofamputatedparts• Hypotension• Proximalinjurytoarm/forearm

c. Howwouldyoustoretheamputatedpartspendingadecisionforpotentialreimplantation?List

two(2)pointsinyouranswer.(2marks)• Doublesealedbag(orbottomshelffridge)• Iceslurry

d. Whatisthemostappropriateregionalanaesthesiatechniqueforthispatient?(1mark)• Combinedradialandmediannnblock• orUSguidedscaleneblock• orvolarplateblock

NB:Notringblock-maypranganartery

Amputations

Careofamputatedparts Xray WashgrosscontaminationwithsterileNS→wrapinsterilegauzelightlysoakedinNS→doubleplasticbaginice/water Orlowertrayfridge Aimtokeepcoolavoidfreezing

Careofstump RemoveanytorniquetappliedbyMAS Directpressurewithsteriledressings-combine Novascularclamping Directedtemporarytourniquet

-onlyifuncontrollablebleedingenroutetotheatre

Timetoreimplantation-ishaemiatime Warm6-8hrs Cool12hrs(upto24hrs)

PrognosticfactorsforfavourableoutcomeAmputatedpartfactors Cleancutvscrush/shear/degloving Durationoftimebetweeninjuryandsurgery Minimalcontamination/infection Minimalwater/shrinkageeffectatedges Site/musclecontent →wristbetterthanforearm→tendonsrepairbetterthanmuscle →fingersdowellifamputateddistaltoFDPorproxFDSinsertion(worstbetDIP&PIP) →worstiftwolevelinjuryPatientfactors Age→childrendobetter Preexistinghealth(DM,PVD,steroidsdoworse) →smokerspoorsuccessrate

Relativecontraindicationstoimplantation Longdurationbetweentimeofinjury→Sx(>6/24warm,>12coldischemiatime) CrushwithextensiveSTI Peripheralvasculardisease Grosslycontaminated/infectedwound Devitalisedtissue Otherlife-threateninginjurieswhichtakeprecendence Siteofamputationinpresenceofsignificantneurologicalinjury(egBPdisruption)

Don'tforgetIVAbsTetanusprophylaxis-toxoid+/-TIGAnalgesiaSplintFastManagementofotherinjuries-Secondarysurvey

Question8(12marks)

A6yearoldboypresentswithaleftsupracondylarhumeralfracture.

a. Listtwo(2)typeofpainscoringsystemsthatyoucouldapplytothischild.(2marks)• WongBakerFaces (3-18)• FLACC (2/12-18)• Visualanalogue (6-18)NB:Numerical (8+yrs)

b. Listtwo(2)reasonswhyapainscoreisused.(2marks)

• Objectiveassessmentofpainispoor• Allowsassessmentofefficacyofanalgesia

c. Listfour(4)indicationsforGAMPinthispatient.(4marks)

• Distalneurocompromise• Distalvascularcompromise• Skincompromise• Capitellumposteriortoanteriorhumeralline(dorsalangulation>10°)• <50%bonycontact• Medial/lateralangulationEspif>10°• Anteriordisplacement

d. Listfour(4)piecesofadvicethatyouwouldgivetothisboy’sparentifthepatientisabletobe

dischargedfromtheemergencydepartment.(4marks) • Postsedationadvice• PostPOPadvice

§ Indicationstoreturnforreview• POPcheckplan• Analgesiaadvice• Followuparrangements

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Question9(12marks)

A46yearmanisbroughttoyouremergencydepartmentwithsuspectedalcoholwithdrawal.

a. List seven (7) of the 10 scale domains that form theAlcoholWithdrawal Assessment Scale (7marks) • N&V• Tactiledisturbance• Tremor• Paroxysmalsweating• Auditorydisturbance• Visualdisturbance• Anxiety• Agitation• Headache• Orientationandcloudingofsensorium

A35yearoldmaleisidentifiedashaving“verysevere”alcoholwithdrawal.

b. Statefive(5)keymanagementstepsforthispatientoverthenext1hour.(5marks)• Nonstimulatingenvironment• Provideadequatehydration• RxThiamine&multivitamins• Rxhypoglycaemia• IVdiazepam5mg-repeatto4xover1st30minthen30minutelyasrequired

This resource is produced for the use of University Hospital, Geelong Emergency staff for preparation for the Emergency Medicine Fellowship written exam. All care has been taken to ensure accurate and up to date content. Please contact me with any suggestions, concerns or questions. Dr Tom Reade (Staff Specialist, University Hospital, Geelong Emergency Department) Email: tomre@barwonhealth.org.au November 2017