UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION

WEEK1–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)9minutes A40yearoldmalepresentstotheEDwithfeverandconfusionfor24hours.Hehasjustreturnedfromonemonthback-packingthroughPapuaNewGuineaandIndonesia.Hisobservationsare:PR120bpmBP130/80mmHgRR16bpmTemp39.5°CGCS13(V3)

a. Listfour(4)likelydifferentialdiagnosesforthispresentation.Foreachdiagnosislisttheexpectedincubationperiodpriortoclinicalfeatures.(8marks)

NB: GCS↓ Don’tpickaDDxforwhichyouhavenoideaofincubationperiod!

Differentialdiagnosis(5marks)

Expectedincubationperiod(5marks)

Malaria-Cerebral/FalciparumMANDATORY

Falciparum:6–30days(98%onsetwithin3monthsoftravel)Vivax:8daysto12months(almost½haveonset>30daysaftercompletionoftravel)

Typhoidfever-MANDATORY 8-14days(3days-1month)Japaneseencephalitis(endemicarea) 3–14days(1–20days)Entericfever 7-8days(3-60daysScrubTyphus 6-20daysLeptospirosis(wildrodents/water) 7-12daysDengue(notusuallyACS) 4-8days(3-14)Meningitis-bacterial Hours-daysPneumonia Hours-daysViralencephalitis 3–14days(1–20days)

b. Listfour(4)keyinvestigationsthatyoumayperformtoassistwiththediagnosis.(4marks)NB “toassistwiththediagnosis”

• Bloodfilms-T&T• Bloodcultures• Serology-Dengue• Serology--viral• CTB

c. Listtwo(2)specificmedicationsthatyouwouldconsiderasempirictreatmentpriortoobtaining

confirmatorytestsforthispatient.Foreach,listyourdoseandroute.(6marks)

Medication(2marks)

Dose(2marks)

Route(2marks)

1 Ceftriaxone 2g IV

2 Artesunate(1stlineseveremalaria) OR(ifparenteralartesunateisnotimmediatelyavailable)quininedihydrochloride

2.4mg/kg20mg/kg

IV

Youshouldknowthefeatures/Dx/Mxof:Malaria,Dengue,Typhoid,Yellowfever,Travellers’Diarrhoea&Schistosomiasis

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

ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)

Ihaven’tfoundabetterarticlethanthisonthistopic-stillrelevantdespiteitsage

Question2(8marks)6minutes

A59yearoldobeseman receives5mgof intravenousmorphine foranalgesia forabdominalpain.Thirtyminuteslater,hisGCShasfallento12andinvestigationsareperformed. ReferenceRange FiO2 0.21 pH 7.24 7.35-7.45 pCO2 92mmHg 35-45 pO2 45mmHg 80-95 Bicarbonate 49mmol/L 22-28 Baseexcess 10 -3-+3 O2saturation 78% >95 Lactate 1.2mmol/L <1.3 Na+ 142mmol/L 134-146 K+ 3.8mmol/L 3.4-5 Cl- 86mmol/L 98-106 Glucose 11.4mmol/L 3.5-5.5 Haemoglobin 184g/L 135–180 CarboxyHb 7% <6%

a. Providetwo(2)calculationstohelpyoutointerprettheseresults. Derivedvalue1: A-agradient=150-(1.25x92)-45=-10thereforenonA-agradient Derivedvalue2: ExpectedHCO3=

ACUTE:foreveryincreasedin10ofCO2above40,HCO3↑by1from24=24+5=29 CHRONIC:forevery↑in10ofCO2above40,HCO3↑by4from24=24+(5x4)=44 Thereforefullcompensationwithsuperimposedmetabolicalkalosis

Simplerespiratoryalkalosis:Acute↓ HCO3-2in10minevery10mmHg↓ PCO2.Minimumof18∴<18highlysuggestiveofmetabolicacidosis(pCo2valuescannotbenegative)Chronic ↓ HCO3-5ifsustainedfor2-3days

b. Usingthescenarioandthederivedvalues,definetheprimaryabnormality/s.(2marks) • Respiratoryacidosis:

o Acuteonchronic• Superimposedmetabolicalkalosisnotaccountedforbycompensationforrespiratoryacidosis

o secondarytovomitinginsettingabdominalpain

c. Usingthescenarioandthederivedvalues,definethesecondaryabnormality/s.(2marks)• MetabolicalkalosisascompensationforchronicRespacidosis

d. Provideaunifyingexplanationfortheseresults.(2marks)• Chronicrespacidosissecondarytopossiblehypoventilationfromobesity,+/-obstructive

sleepapnoea• Respiratorydepressionandhypercapniaexacerbatedbyopioids->lifethreateninghypoxia• Acutedeteriorationsecondarytodepressioncentralrespiratorydrivefromadministration

opioidswithnoevidenceofunderlyingV/Qmismatch• Metabolicalkalosisinsettingofabdominalpainandpossiblevomiting/GIlosses

Question3(12marks)6minutes

A42yearoldfemalepresentsviaprivatecartotheEDwithsevererightflankpain.

Herobservationsare:BP70 PR150 RR16 Temp37°C GCS15

a. Listfour(4)likelydifferentialdiagnosesforthisscenario.(4marks)

NB: Dxneedstoexplainobswhichshowshock.Ie“ectopicpregnancy”isnotcorrect Rupturedovariancystmaycausethispicturebutmostcysticbleedingisusuallycontained

• Intra-abdo/retroperitonealbleed• Rupturedectopicpregnancywithhaemorrhageshock• Pyelonephritiswithsepsis-egG-ve• Renalcolicwithobstruction&sepsis• Rupturedappendicitiswithperitonitisandsepsis

b. Listfour(4)investigationsthatyouwouldperformtoassistwiththediagnosis.Stateone(1)justificationforeachchoice.(8marks)

NB: “toassistwiththediagnosis” “straighttotheatre”isnotaninvestigation

Investigation Justification

FASTscan

Rapidlydiagnoseintraperitonealbleed/fluidascauseforshock

CTabdo/pelvis

Diagnoseretroperitonealbleedorfreefluid,hydronephrosis/perinephricstranding,aorta,biliarydisease,intraperitonealgasetc

CTKUB Dxobstructedkidney/renalcalculi

OnlyifContrastCIaswouldexpectacontrastscan

βhCG

SupportsDxpregnancy/ectopic

FWT ScreenforUTI

Question4(14marks)6minutes

A72yearoldmalepresentstoEDwithextremeshortnessofbreath.HehasahistoryofCOPDandisotherwisewell.Heis70kg.Hehasnotbeengivenanymedications.Hisobservationsare: BP130PR120RR36Temp38.2°CGCS15

a. List three (3)medications thatyouwouldconsiderusing forhis initial treatment. Listdoseandrouteofadministration.(9marks)

Drug(3marks)

Delivery(3marks)

Dose(3marks)

Ventolin Neb(useairifsats>88%)

5-10mg

(carefulwithoverdosing)

Steroid:

Prednisolone

Dexamethasone

Hydrocortisone

Ō

IV

IV

50mg

10mg

250mg

Antibiotic:

Penicillin

Ceftriaxone

IV

IV

2.4g

1g

Hedoesnotrespondtoyourtreatmentandrequiresintubation.

b. Stateyourinitialventilatorsettings.(3marks)

Ventilatorsettings

Rate Low8-10

Tidalvolumes 6-8ml/kg

I:Erate Loweg1:4(prolongedexpiatoryphase)

c. Statetwo(2)reasonsforyourchoiceoftheseventilationsettings.(2marks)

• Controlled/Permissivehypercapnia-allowlongexpirationandpreventdynamichyperinflationwithpermissivehypercapnia

• ReduceIPs• Lungprotectiveventilation/sedation• Preventdynamichyperinflation/barotraumabyallowingforlongexhalationandlowI:E• Minimiseriskofvolutrauma

Question5(12marks)6minutes

A6yearoldboypresentswith1dayofthisrash.

a. Listfive(5)diagnosticfeaturesofthisrash.(5marks)

• Targetlesions• Welldemarcated/discreteinitially• Coalescewithmoreadvanceddisease• Centralareausuallyslightlyoffcentre• Centreareamaybepale/erythematous/darkrad/purple• Widespread,nosparedareas(mildtendstobeperipheral)• Varyingsizes

b. List5likelycausesforthisrash.(5marks)

Herpessimplexvirus Mycoplasma Drugssulphas,penicillinsNSAID’sphenothiazinesanticonvulsants

VirusesVaricellaCMVAdenoHepatitisViralimmunisation

CollagenVascularDiseaseProtozoanInfectionFungalInfectionSkinAllergies

c. Listtwo(2)featuresofthisdiseasethatdifferentiatesmildtoseveredisease.(2marks)

• Epithelialloss→absent→EMultiformaepresent→SJSvsTEN• %BSAinvolved<10%→SJS>30%→TEN

Question6(14marks)6minutesA52yearoldmalepresentstoEDwithchestpain.HisECGisshown.

a. Statefour(4)abnormalitiesshownonthisECG.(4marks)• Wenckebachtype,Mobitztype12nddegreeHB• STEII,III,aVF(1mm,2mm,2mmrespectively)• STDV2-V6,I,aVL• BiphasicTwavesI,aVL,V2,V3

b. Statefour(4)significantimplicationsofthesefindings.(4marks)

• InfSTEMI-meetscriteriaforurgentreperfusionRx• Likelyposteriorinvolvement

o largeinfarcto carewithMorph/GTN&fluidloadif↓BP

• Anticipatefurtherbradycardia/block/-vechronotropicinstability

c. List two (2) specific complications that youmay anticipate for this patient within the first 30minutesofyourcare.Stateone(1)specifictreatmentforeachcomplication(4marks)

Complication(3marks)

Specifictreatment(3marks)

Cardiogenicshockwith

hypotension

FluidsUrgentPCI(betteroutcomesincariogenicshockcfthrombolysis)

CHB/bradycardia Atropine-300-600mcgPaceAdrenaline(carewith+veChronotropes)Isoprenaline(AVnodesuppliedbyRCA90%)

Ventriculararrhythmiasesp

VT/VF-

DCR

↑Pain UrgentPCIFentanylforongoingpain

Question7(13marks)6minutes

a. Completethefollowingstatementwithfive(5)statements.(5marks)

Apersongivesvalidinformedconsentifthey:

• havecapacitytogiveinformedconsenttothetreatmentormedicaltreatmentproposed• havebeengivenadequateinformationtoenablethepersontomakeaninformeddecision• havebeengivenareasonableopportunitytomakethedecision• havegivenconsentfreelywithoutunduepressureorcoercionbyanyotherperson• havenotwithdrawnconsentorindicatedanyintentiontowithdrawconsent

b. Listthree(3)circumstancesinwhichapatientcanbelegallyheldagainsthis/herwishes.(3

marks)

• Insituationsinwhichurgenttreatmentisrequiredtopreventmorbidityormortalityand:• Thepatientisa:

o Minoro RecommendedundertheMentalHealthacto MedicalPowerofAttorneyexistsandagreestodetainmento Abnormalmentalstateo Significantphysiologicalderangemento Undertheinfluenceofalcohol/drugso Behaviourinconsistentwithpersonality(fromfamily,friends,GP,oldnotes)

c. Definemedical"negligence".(1mark)

• Negligenceisafailuretotakereasonablecaretoavoidcausinginjuryorlosstoanotherperson

d. Listthefour(4)legalconditionsrequiredtoprovenegligence.(4marks)• adutyofcareexists• breachofduty-thatthebehaviororinactionofthedefendantinthecircumstancesdidnot

meetthestandardofcarewhichareasonablepersonwouldmeetinthecircumstances• damage-thattheplaintiffhassufferedinjuryorlosswhichareasonablepersoninthe

circumstancescouldhavebeenexpectedtoforesee• causation-thatthedamagewascausedbythebreachofduty

NB:MentalHealthactsvaryacrossAus&NZ-theactbelowispresentedtogivesomeguidelinesandexplanations

AnexcerptfromMentalHealthAct2014(Vic)

TheinformedconsentofapersonmustbesoughtbeforetreatmentormedicaltreatmentisgiventothepersonundertheMentalHealthAct2014.AllpeoplearepresumedtohavecapacitytogiveinformedconsenttotreatmentormedicaltreatmentregardlessoftheirageorlegalstatusundertheMentalHealthAct.TheMentalHealthActsetsout:

• therequirementsforinformedconsent• thecircumstancesinwhichtreatmentcanbeprovidedtoapatientwithoutthepatient’sinformed

consentandtheprocessthatmustbeundertakenbeforeprovidingthattreatment• theprocessforprovidingmedicaltreatmenttoapatientwhodoesnothavecapacitytogiveinformed

consenttomedicaltreatment.InformedconsentTheinformedconsentofapersonmustbesoughtbeforetreatmentormedicaltreatmentisgiventoapersoninaccordancewiththeMentalHealthAct.Apersongivesinformedconsentifthey:

• havecapacitytogiveinformedconsenttothetreatmentormedicaltreatmentproposed• havebeengivenadequateinformationtoenablethepersontomakeaninformeddecision• havebeengivenareasonableopportunitytomakethedecision• havegivenconsentfreelywithoutunduepressureorcoercionbyanyotherperson• havenotwithdrawnconsentorindicatedanyintentiontowithdrawconsent.

CapacityThepersonseekinginformedconsentofanotherpersontoatreatmentormedicaltreatmentmustpresumethattheotherpersonhasthecapacitytogiveinformedconsent.Thismeansthateveryonemustbepresumedtohavecapacitytomakedecisionsabouttheirtreatmentormedicaltreatment,regardlessoftheirage(e.g.youngpeopleorolderpersons)orwhethertheyareapatientundertheMentalHealthAct.TheMentalHealthActcontainsanumberofguidingprinciplestoassistapersonwhoisrequiredtodeterminewhetherapersonhascapacitytogiveinformedconsent.Adequateinformation

Apersonhasbeengivenadequateinformationtomakeaninformeddecisionif:• theyhavebeengivenanexplanationoftheproposedtreatmentormedicaltreatment,includingthe

purpose,type,methodandlikelydurationofthetreatmentormedicaltreatment• theyhavebeengivenanexplanationoftheadvantagesanddisadvantagesofthetreatmentormedical

treatmentincludinginformationabouttheassociateddiscomforts,risksandcommonorexpectedsideeffectsofthetreatmentormedicaltreatment

• theyhavebeengivenanexplanationofanybeneficialalternativetreatmentsthatarereasonablyavailable,includinganyinformationabouttheadvantagesanddisadvantagesofthesealternatives

• theyhavereceivedanswerstoanyrelevantquestionsthatthepersonhasaskedandanyotherrelevantinformationthatislikelytoinfluencetheperson’sdecision

• theyhavebeengiventherelevantstatementofrightsandhadthatstatementexplainedtotheminamannerthatthepersonismostlikelytounderstand.

ReasonableopportunityApersonhasbeengivenareasonableopportunitytomakeadecisionif:

• thepersonhasbeengivenareasonableperiodoftimetoconsiderthemattersinvolvedinthedecision• thepersonhasbeengivenareasonableopportunitytodiscussthedecisionwiththeregisteredmedical

practitionerorotherhealthpractitionerproposingthetreatmentormedicaltreatment• thepersonhasbeengivenareasonableamountofsupporttomakethedecision• thepersonhasbeengivenareasonableopportunitytoseekanyotheradviceorassistanceinrelationtothe

decision.

GivenconsentfreelywithoutunduepressureorcoercionInformedconsentmustbefreelygiven.Apersonmustnotfeeltheyhavetogiveinformedconsentsimplybecausetheclinicianbelievesitisnecessaryfortheirtreatmentorintheirbestinterestsortopleaseafamilymemberorcarer.HavenotwithdrawnconsentApersoncanwithdrawconsentatanytime.Apersoncanwithdrawconsentverballyorinwriting.Apersoncanwithdrawconsentbeforethetreatmentstartsorduringacourseoftreatment.Ifthepersonwithdrawsconsent,thetreatmentmuststop.Apersonwithdrawsconsentiftheysayorindicatebytheirbehaviourthattheydonotconsenttothetreatment.ProvidingtreatmentwhenapatientdoesnotgiveinformedconsentTheMentalHealthActrequiresthatpatientsaregiventreatmentfortheirmentalillness.Onlythepatientcangiveorrefuseinformedconsenttotreatment.Nootherpersonorbodyauthorisedbylawtomakedecisionsforthepatientcangiveorrefuseinformedconsenttotreatment.ThismeansthataguardianorapersonresponsibleundertheGuardianshipandAdministrationAct1986oranagentundertheMentalTreatmentAct1988cannotgiveorrefuseinformedconsentonbehalfofapatient.However,theMentalHealthActpermitsanauthorisedpsychiatristtomakeatreatmentdecisionforapatientwho:

• doesnothavecapacitytogiveinformedconsenttothetreatmentproposedbytheauthorisedpsychiatristor

• hascapacitytogiveinformedconsenttothetreatmentproposedbytheauthorisedpsychiatristbuthasnotgiveninformedconsenttothattreatment.

Theauthorisedpsychiatristcanmakeatreatmentdecisionforthepatientiftheauthorisedpsychiatristissatisfiedthatthereisnolessrestrictivewayforthepatienttobetreatedotherthanthetreatmentproposedbytheauthorisedpsychiatrist.TheMentalHealthActdoesnotpermitanauthorisedpsychiatristtomakeatreatmentdecisionaboutelectroconvulsivetreatmentorneurosurgeryformentalillnessforapatient.Seeelectroconvulsivetreatmentandneurosurgeryformentalillnessformoreinformation.DeterminingtheleastrestrictivetreatmentIndeterminingwhetherthereisnolessrestrictivewayforthepatienttobetreated,theauthorisedpsychiatristmusthaveregard,totheextendthisisreasonableinthecircumstances,toallofthefollowing:

• thepatient’sviewsandpreferencesabouttreatmentofhisorhermentalillnessandanybeneficialalternativetreatmentsthatarereasonablyavailableandthereasonsforthoseviewsandpreferences,includinganyrecoveryoutcomesthatthepatientwouldliketoachieve

• theviewsandpreferencesofthepatientexpressedinhisorheradvancestatement• theviewsofthepatient’snominatedperson• theviewsoftheguardianofthepatient• theviewsofacarer,iftheauthorisedpsychiatristissatisfiedthatthetreatmentdecisionwilldirectly

affectthecarerandthecarerelationship• theviewsofaparentofthepatient,ifthepatientisundertheageof16years• theviewsoftheSecretarytotheDepartmentofHumanServicesifthepersonisthesubjectofa

custodytoSecretaryorderoraGuardianshiptoSecretaryorder• thelikelyconsequencesforthepatientiftheproposedtreatmentisnotperformed• anysecondpsychiatricopinionthathasbeengiventotheauthorisedpsychiatrist.

ProvidingmedicaltreatmenttoapatientwhodoesnothavecapacityMedicaltreatmentcanbeadministeredtoapatientifthepatientgivesinformedconsenttothemedicaltreatment.Apatientwithcapacitycanrefusemedicaltreatment.Therequirementsforinformedconsenttomedicaltreatmentarethesameastherequirementsfortreatment.SubstituteconsenttomedicaltreatmentTheMentalHealthActsetsoutrequirementsforwhocanprovidesubstituteconsentforpatients18yearsoraboveandpatientsunder18yearsofage.AdultpatientsMedicaltreatmentmaybeadministeredtoapatient18yearsorolderwhodoesnothavecapacitytogiveinformedconsenttomedicaltreatment,withtheconsentofthefirstpersonofthefollowinglistedbelowwhoisreasonablyavailable,willingandabletomakeadecisionabouttheproposedmedicaltreatment:

• apersonappointedbythepatientundersection5AoftheMedicalTreatmentAct(thepatient’smedicalagentorguardian)

• apersonappointedbytheVictorianCivilandAdministrativeTribunaltomakedecisionsconcerningtheproposedmedicaltreatment

• apersonappointedunderaguardianshiporderwithinthemeaningoftheGuardianshipandAdministration

Actwithpowertomakedecisionsconcerningtheproposedmedicaltreatment(thepatient’sguardian)• apersonappointedbythepatient(beforethepatientbecameincapableofgivinginformedconsent)asan

enduringguardianwithinthemeaningofGuardianshipandAdministrationActwithpowertomakedecisionsconcerningtheproposedtreatment(thepatient’senduringguardian)

Patientsunder18yearsofageMedicaltreatmentmaybeadministeredtoayoungpatientunder18yearsofagewhodoesnothavecapacitytogiveinformedconsenttomedicaltreatment,withtheconsentof:

• apersonwho,inrelationtothepatient,hasthelegalauthoritytoconsenttomedicaltreatmentandwho,inthecircumstances,isreasonablyavailable,willingandabletomakeadecisionabouttheproposedmedicaltreatmentor

• theauthorisedpsychiatrist.Amedicaltreatmentdecisionmaybemadebythefirstpersonwhois‘reasonablyavailable,willingandable’tomakeadecisionaboutthepatient’smedicaltreatment.Theauthorisedpsychiatristmayconsenttomedicaltreatmentbeingadministeredtoapatientwhodoesnothavecapacitytogiveinformedconsentiftheauthorisedpsychiatristissatisfiedthatthemedicaltreatmentwouldbenefitthepatient.MakingasubstitutedmedicaltreatmentdecisionTheMentalHealthActrequirestheauthorisedpsychiatristtohaveregardtothefollowingmatterstotheextentthatisreasonableinthecircumstanceswhendeterminingwhetheramedicaltreatmentwouldbenefitapatient:

• thepatient’sviewsandpreferencesaboutmedicaltreatmentandanybeneficialalternativemedicaltreatmentsthatarereasonablyavailableandthereasonsforthoseviewsandpreferences,includinganyrecoveryoutcomesthatthepatientwouldliketoachieve

• theviewsofthepatient’snominatedperson• theviewsoftheguardianofthepatient• theviewsofacarer,iftheauthorisedpsychiatristissatisfiedthatthetreatmentdecisionwilldirectlyaffectthe

carerandthecarerelationship• theviewsofaparentofthepatient• theviewsoftheSecretarytotheDepartmentofHumanServicesifthepersonisthesubjectofacustodyto

SecretaryorderoraGuardianshiptoSecretaryorder• ifthemedicaltreatmentislikelytoremedytheconditionoflessenthesymptomsofthecondition• thelikelyconsequencesforthepatientifthemedicaltreatmentisnotperformed• anysecondopinionofaregisteredmedicalpractitionerthathasbeengiventotheauthorisedpsychiatrist.

Iftheauthorisedpsychiatristisoftheopinionthatapatientwhodoesnotcurrentlyhavecapacitytogiveinformedconsenttomedicaltreatmentislikelytohavecapacitytogiveinformedconsentwithinareasonableperiodoftime,theauthorisedpsychiatristmustnotconsenttothemedicaltreatmentunlessthedelayinadministeringorperformingthemedicaltreatmentcouldresultinseriousharmto,ordeteriorationin,thementalorphysicalhealthoftheperson.UrgentmedicaltreatmentTheMentalHealthActpermitsa‘healthpractitioner’toperformmedicaltreatmentonapatientwhodoesnothavecapacitytogiveinformedconsenttothemedicaltreatmentwherethemedicaltreatmentneedstobeperformedasamatterofurgency.Amatterofurgencymeanswheremedicaltreatmentneedstobeperformed:

• tosavethepatient’slifeor• topreventseriousdamagetothepatient’shealthor• topreventthepatientsufferingorcontinuingtosuffersignificantpainordistress.

Thereisnorequirementthatthehealthpractitionerseektheconsentofanyotherpersonwhoislegallypermittedtogiveconsenttomedicaltreatmentonbehalfofthepatientwherethehealthpractitionerissatisfiedthatthemedicaltreatmentisrequiredasamatterofurgency.However,ifsuchapersonisreasonablyavailable,willingandabletogiveconsenttotheurgentmedicaltreatment,thatperson’sconsentshouldbesoughtasamatterofgoodclinicalpractice.Thereisnorequirementthatthe‘healthpractitioner’beregisteredundertheHealthPractitionerRegulationNationalLaw(Victoria)Act2009.Ahealthpractitionerwhoingoodfaithcarriesoutorsupervisesthecarryingoutofmedicaltreatmentinthereasonablebeliefthattherequirementsforurgentmedicaltreatmenthavebeencompliedwithisnot:

• guiltyofassaultorbattery• guiltyofprofessionalmisconductorunprofessionalconduct• liableinanycivilproceedingsforassaultorbattery.

Thisprotectionfromliabilitydoesnotaffectanydutyofcareowedbythehealthpractitionertoapatient.

Question8(13marks)6minutesA62yearoldfemalepresentstoEDwithmassivehaematemesis.Shehasahistoryofalcoholdependence.Hervitalsignsonpresentationare:GCS15 BP70PR150RR16 Temp37°C

a. Listfive(5)likelydifferentialdiagnosesforthecauseofherbleeding.(3marks)NB:“Massive”“alcoholdependence”&sheisinshock• GOVarices• PUD• Oesophagitis• Alcoholicgastropathy• DU• MWtear• Coagulopathy+gastritis/anyofabove• Aorto-entericfistula• Angiodysplasia

b. Listthree(3)indicationsforurgent(<1hour)gastroscopy.(3marks)• Knownvaricesandongoingmassivehaematemesis/haemodynamicinstability• Persistenthaemodynamicinstabilitydespiteappropriateresuscitation• Ongoingmassivehaematemesis

c. Other than endoscopy, list three (3) steps in the management of her

haemodynamicstate.Listone(1)detailforeachstep.(8marks)

Management(3marks)

Detail(3marks)

Fluids IVnormalsalinebolus250mlReassesswithplanforearlybloodproductsAimforpermissivehypotensione.g.SBP80-90mmHg

Blood-activateMTP Evidencehaemorrhagicshock,startwithO- ifdelay, thenaimrationXMbloodPRBC:FFP:platelets1:1:1

Octreotide 50mcgbolustheninfusion50mcg/hr48hrsDecreases bleeding via increased intragastric pH (noevidence)

Reversecoagulopathy FFP2-4units,prothrombinX20-50IU/kg????,vitaminsK10mgIV

Pantoprazole 80mgIVtheninfusion8mg/hr↓ LOS↓ needforendoscopictherapydoes not reduce transfusion req, re-bleeding, need forsurgeryordeathat30d

NB:Maycombinefluidsandbloodinto1point

Question9(13marks)9minutesA2yearoldfemalepresentstoEDafteraccidentalingestionof2x400mgrapidreleasecarbamazepine

tablets.

a. Listthree(3)mechanismsofpossibletoxicityfromthisexposure.(3marks)

• Nachannelblocker• NAreuptakeinhibitor• Anticholinergic-muscarinicandnicotinic• InhibitscentralNMDAadenosinereceptors

b. Listtwo(2)ECGfindingsthatwouldsuggestsignificanttoxicityfromthisingestion.(2marks)

• 1stdegreeHB• QRSprolongation• Sinustachycardia• DominantRwaveaVR>3mm• R/SratioinaVR>0.7

c. List two (2)methodsofdecontaminationorelimination.Stateone (1) indication foruse in this

patientforeachmethod.(4marks)

Method(2marks)

Indication(2marks)

AC Early&asymptomatic<50mg/kg:allingestionsif>50mg/kg:onlyafterintubatedasneedairwayprotection

MDAC ETT&BSpresent

Haemodialysis Prolongedcoma>48/24haemodynamicinstabilityhighserumlevelsafter48/24

d. Listfour(4)criteria,specifictothisexposure,thatneedtobemettoallowsafedischarge. (4marks)

NB: “specific to this exposure”- safe environment probably ok, “clinically well” probably not- toobroadandapplicabletoanyOD

• Observefor>8/24• Daylighthour• Nosedation• Noanticholinergiceffects• Safeenvironment

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