Monash SAQs: Paeds, Admin, Resus, ECG

A 1 year old presents to your ED with a history of a few days of fever and general unwellness. He has a large peeling bulla/blistering palmar aspect of his hand. List 4 differentials. List 4 other features you would look for on examination to support your most likely diagnosis. (4 marks) What Ix would you do. What is the complications What is the treatment.

1. Kawasakis disease 2. Staph scalded skin syndrome or toxic shock, can be strep 3. Drug induced - Stevens-Johnsons or similar 4. Consider traumatic burn, neglect, (?NAI), although stem not suggestive 1.(Elevated temperature?) 2. Lymphadenopathy 3. Conjunctivitis 4. Mucous membrane involvement - Strawberry tongue. lip peeling 5. Polymorphic rash (4 marks) - any of these acceptable, note the peeling is generally in convalescent so the rash and acute changes may not be present RMCH says: polymorphous rash bilateral (non purulent) conjunctival injection mucous membrane changes, e.g. reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa peripheral changes, e.g. erythema of the palms or soles, oedema of the hands or feet, and in convalescence desquamation cervical lymphadenopathy (> 15 mm diameter, usually unilateral, single, non purulent and painful) Other relatively common features include arthritis, diarrhoea and vomiting, coryza and cough, uveitis, gall bladder hydrops. Some patients get myocarditis. Investigations: All patients should have 1. ASOT / Anti DNAase B 2. Echocardiography (at least twice: at initial presentation and, if negative, again at 6 - 8 weeks). 3. Platelet count (marked thrombocytosis common in second week of illness) Other tests are not diagnostic or particularly useful. The following may be seen: neutrophilia raised ESR + CRP mild normochromic, normocytic anaemia hypoalbuminaemia Elevated liver enzymes Thrombocytosis and desquamation appear in the second week of the illness or later. Their absence earlier does not preclude the diagnosis. vasculitis coronary artery aneurysms Treatment: Admit. Intravenous immunoglobulin Aspirin 3-5 mg/kg daily for 2 months.

What is the differential diagnosis for the ECG. The pt has a BP of 60 systolic. Describe four (4) different steps you would take to treat her hypotension

A sinusoidal, wide complex rhythm between 80-120bpm with QRST fusion: Sodium channel blockade. Hyperkalaemia Accelerated idioventricular rhythm (AIVR) Massive STEMI Treatment of hypotension: Always think about writing end points! 1.IV Fluid Eg N/saline with estimated amount or end point. 2.Sodium Bicarbonate 50-100mmol IV stat then every 3-5 min until perfusing rhythm then continue (q 15-30min) aim QRS < 100msec 3.Inotrope eg Adrenaline / Noradrenaline 4.Other ETT/hyperventilate/pH 7.5 Balloon pump/ECMO/Bypass Intralipid Insulin Euglycemia Rx Rx for hyperK Sage Advice • Please don't write - Repeat as necessary - Repeat as required

NB Don't forget anaphylaxis will need the same ventilator settings as asthma - I:E 1:4, RR 8, moderate hypercapnoea. And once intubated give continuous salbutamol via MDI into the circuit (not a nebuliser!) Bag ventilate til stabilised.

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NB Pts with chronic CO2 retention will have high bicarb and high base excess e.g. +7 (remember acidotic pts will have a base deficit - this should be resolving with affective resuscitation).

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The pros and cons of the different medications to treat acute atrial fibrillation in ED.

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Name 2 areas to avoid placement of defib pads. (2 marks)

ecg electrodes Medication patches Breast tissue Implanted pacemaker/ICD (at least 12-15 cm away) (any two)

Pregnant pt with a PE becomes hypotensive. List 4 treatment options (2 marks)

fluids, inotropes, thrombolysis, embolectomy

What are the causes of papilloedema.

intracranial - space-occupying lesions (e.g. neoplasms, trauma, infection, and vascular causes) - benign intracranial hypertension (trauma, drugs, idiopathic, Addisons, sinus thrombosis) - central venous sinus thrombosis meningoencephalitis CSF - hydrocephalus - obstructive, communicating (production vs. absorption of CSF) - high CSF protein — e.g. Guillain-Barre Syndrome extracranial - central retinal vein occlusion (CRVO) - retro-orbital mass - hypertension (grade IV)

A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to "deal with the JMO". The doctor says he only wanted to take some as prophylaxis against possible meningococcus. What key principles should you consider in your discussion with the JMO?

• Non-judgemental, non-confrontational, confidential, document discussion. • "Stealing" drugs is potentially serious - disciplinary/employment ramifications • Doctor needs counselling - ?apology etc • Concern about infection not entirely unreasonable though prophylaxis only indictaed if meningococcus confirmed & close exposure (e.g. suctioning, intubation)

3 yr old with limp. Name the 8 most common non traumatic causes.

• Perthes disease • transient synovitis • septic arthritis • osteomyelitis • Stills disease (systemic onset juvenile idiopathic arthritis) • juvenile ankylosing spondylitis • Ewing sarcoma • Leukaemia • vaso-occlusive - sickle cell crisis

2 day old with jaundice. List 6 differentials you would consider for this neonate. (3 marks) List the most relevant investigations which you would consider in the ED. (5 marks) What level of conjugated bilirubin is significant. What Ix would you do next.

• Rhesus haemolytic disease or ABO incompatibility • congenital spherocytosis • G-6-PD deficiency • Infection/ sepsis • Hypothyroidism • biliary atresia. Score 0.5 marks for each reasonable diagnosis upto 3 marks, but score 0/3 if has physiological jaundice on the differential which usually presents late. • serum bilirubin - conjugated and unconjugated • FBC and blood film; reticulocyte count • Coomb's test • TFTs • Blood culture If conjugated bilirubin > 15% then do an abdo USS.

What are the major modifications needed to be made to this algorithm in the case of unintentional (environmental) hypothermia? (3 marks)

• Start and continue ALS until patient is rewarmed (Temp ≥ 32°C) unless other obvious lethal injuries present • Withhold drugs until temp ≥ 30° C then double interval between giving drugs until temp ≥32°C • Can defibrillate initially 3 x if in VF/VT but then pause (as no effect) until temp ≥30°C • Main therapy is re-warming

A 4 yr old who is wheezey. List 6 features of acute severe asthma (2 marks)

• increased RR >40/min • increased work of breathing with moderate to severe accessory muscle use • marked tachycardia (HR>140 bpm ) but beware relative bradycardia for age. • oximetry in room air <90% • inability to talk in full sentences • drowsiness or confusion

. List 4 assessment parameters are the most useful for suspected septic arthritis in a child with a painful hip (4marks)

• non-wt bearing, • fever 38.5oC, • WCC > 12,000mm, • ESR >40mm NB Kocher criteria 1999 Probability of septic arthritis 1 / 4 - 3%, 2/ 4 - 40%, 3/ 4 - 93%, 4/ 4 - 99%

Delirium vs psychosis. AKA Organic disorder vs psychiatric disorder What are the features suggestive of delirium (7 features).

•age > 40 years with no previous psychiatric history •disorientation •altered conscious state •abnormal vital signs •visual hallucinations •illusions •unconcerned regarding personal privacy

What are the rhythms associated with thrombolysis in MI.

•associated with reperfusion -AIVR -sinus bradycardia -VEBs -non sustained VT NB the incidence of VF and other serious arrhythmias is unchanged with thrombolytics! Resolution of ST elevation is assx with 0% in hospital mortality (and 60% reduction in infarct size).

What are the CXR changes with PE.

•cardiomegaly •elevated hemidiaphragm - common •small pleural effusion •transient pulmonary infiltrates, especially wedge shaped (infarction) •Westermark's sign -prominent PA -abrupt cut off of peripheral vessels -normal vessels should be visible within 2 cm of chest wall Hamton's hump -pleural based opacity (pulmonary infarction) with convex border medially -often in costophrenic angle

How much pericardial fluid is needed to cause cardiac tamponade usually. How much is this on USS. What is the treatment or hypotensive pt with a tamponade (non traumatic).

•usually at least 200 mL in the pericardial space required to cause tamponade •effusion depth usually > 2 cm deep on US Tx of hypotension and tamponade: US guided needle pericardiocentesis with pt at 45 degrees. Sit up, oxygen, fluids, and dobutamine. •sit patient upright whenever possible Respiratory therapy •maximise oxygenation •positive airway pressure usually further decreases cardiac output Inotropic support •unlikely to be effective -dobutamine is the agent of choice as it reduces systemic vascular resistance which may be of benefit -avoid pressor agents IV fluid challenge •improves haemodynamics in 50% of patients •worsens them in 35%! Other therapy •external cardiac compression has little value in the presence of tamponade

Prevention of complaints.

Adequate supervision of juniors. Adequate and timely follow up of Xray and pathology reports. Communication - written info to pts - explanation of waiting times etc.

What are 4 clinical features of life threatening asthma? (4 marks

Answer (2 of mandatory) - 4 of confusion, coma, exhaustion, poor respiratory effort, silent chest, cyanosis, hypotension

What is bifascicular block. What conditions may contribute to bifascicular block.

Bifacicular block: RBBB and LAFB (left axis deviation) IHD Rate related LBB with complete HB CCF Outflow tract obstruction - HTN, aortic stenosis Infiltrative/degenerative Inflammatory - SLE Medications - BB, digoxin

Unwell febrile elderly pt. List your resuscitation goals for the first 6 hours. (4 marks)

CVP 8-12 mmHg MAP >65 mmHg Urine output >0.5ml/kg/hr Central venous sats >70% or mixed venous sats >65% Lactate clearance

What is the management of severe anorexia.

Correct hypokalaemia and hypomagensaemia Thiamine and multivitamins Treat hypoglycaemia Treat hypothermia Watch for refeeding syndrome (hypophosphataemia - weakness and cardiac arrhythmias). Joint medical/pscyh admission

Why does increasing IPAP remove more CO2.

It increases the tidal volume.

List 3 factors that may contribute to access block (3 marks) Give 3 solutions to this problem that may be implemented at the hospital level (3 marks) And at the ED level.

1. Lack of pt beds. 2. Surge in demand - seasonal, aging population. 3. Poor discharge planning. Hospital solutions: More beds. Community services - abx in the home, rehab centres, nursing homes places. Daily ward rounds to discharge pts. Transit lounge, discharge lounge. ED: Early senior doctor decision making. Use of ED short stay unit. Early use of allied health team. Fast track. IT Access to Ix like CT Fast turn around of pathology and radiology.

A morbidly obese pt needs intubating for septic pneumonia. Name 4 problems that may be anticipated and give 2 solutions for each. What ventilatory settings would you start: FiO2 Respiratory rate Tidal volume Positive end-expiratory pressure Peak pressure

1. Difficulty: hypotension Solution: optimise haemodynamics pre-intubation - IV fluid boluses N/S 1000mL, bolus metaraminol 0.5mg, aiming for systolic >90mmHg Difficulty: hypoxia Solution: optimise pre-oxygenation, high flow nasal prongs in addition to BVM with tight seal, bag pt though apnoeic period Difficulty: difficult intubation due to obesity Solution: positioning - ramp position (head up), 1-2 pillows under head, have backup intubation equipment ready - bougie, LMAs, large laryngoscopes Difficulty: difficulty ventilating pt Solution: well sedated and paralysed once intubated, head up to unload diaphragm, airway adjuncts, ensure peak pressure limits, backup equipment, prepared for surgical airway if needed Difficulty: difficult BVM Solution: use of airway adjuncts - Guedels, nasopharyngeal airways, optimise position (as above), Q2. YOUR SETTING FiO2 1.0 Respiratory rate Something sensible - (14 - 25) Tidal volume Something sensible - (350 - 500 mL) Positive end-expiratory pressure 5 - 10cmH2O Peak pressure limit 35 - 40cmH2O

Dealing with complaint. What are the key steps.

1. Acknowledge complaint rapidly. - thank the complainant. 2. Obtain consent if complainant not the pt. 3. Investigate - medical records - talk to staff involved - meet with complainant if serious 4. Root cause analysis 5. Respond - apologise if necessary - express regret 6. Keep record of correspondence 7. Educate and learn from any mistakes made.

Name 7 common symptoms a pt with anorexia nervosa may present to ED with.

1. Chest pain - cardiomyopathy, arrhythmias secondary to electrolytes 2. Palpitations brady or tachyarrhythmias 3. Constipation - 4. Tetany, abdo pain and urinary frequency - hypocalcaemia 5.

What are the complications of fluid therapy? (4 marks)

1. Hypothermia after large volumes of fluid therapy 2. Coagulopathy due to dilution 3. Tissue oedema - limb and abdominal compartment syndrome 4. Pulmonary oedema 5. Hyperchloraemic acidosis with NS 6. Anaphylaxis to synthetic colloids /blood transfusion

Name 3 causes of a tachycardia with pacing spikes before each QRS. What are the other pacemaker problems that might be seen on ECG

1. Pacemaker mediated tachycardia (PMT): - AKA endless loop tachycardia - due to pacemaker acting as a re-entry tachycardia. - retrograde p waves. - the pacemaker limits - results in a paced tachycardia with the maximum rate limited by the pacemaker programming. - can be terminated by slowing AV conduction e.g. adenosine or activation of magnet mode. - newer pacemakers contain programmed algorithms designed to terminate PMT. - may result in rate related ischaemia in the presences of IHD. 2. Sensor induced tachycardia: - modern pacemakers are programmed to allow increased heart rates in response to physiological stimuli such as exercise, tachypnoea, hypercapnia or acidaemia. - sensors may "misfire" in the presence of distracting stimuli such as vibrations, loud noises, fever, limb movement, hyperventilation or electrocautery (e.g. during surgery). - max rate is the pacemaker max rate e.g 160. - a magnet will terminate it. 3. Runaway pacemaker: This potentially life-threatening malfunction of older-generation pacemakers is related to low battery voltage (e.g. overdue pacemaker replacement). The pacemaker delivers paroxysms of pacing spikes at 2000 bpm, which may provoke ventricular fibrillation. Paradoxically, there may be failure to capture — causing bradycardia — because the pacing spikes are very low in amplitude (due to the depleted battery voltage) and because at very high rates the ventricle may become refractory to stimulation. Application of a magnet can be life saving but definitive treatment requires replacement of the pacemaker. Other PPM probems: 1. Output failure - no pacing when it should - reduced or absent pacing spikes. - multiple causes including oversensing, wire fracture, lead displacement, or interference. 2. Failure to capture - pacing spikes but no QRS. - due to electrode displacement, wire fracture, electrolyte disturbance, MI or exit block. 3. Undersensing - occurs when the pacemaker fails to sense native cardiac activity. - results in asynchronous pacing. - causes include increased stimulation threshold at electrode site (exit block), poor lead contact, new bundle branch block or programming problems. - ECG findings may be minimal, although presence of pacing spikes within QRS complexes is suggestive of undersensing. 4. Oversensing - can occur and native beats are inhibited. - electrical signals (eg muscle contactions) are inappropriately recognised as native cardiac activity and pacing is inhibited. - there may be no change on ECG.

A 4 year old boy is brought to your ED having sustained a 4cm eyebrow laceration following a fall at a playground. He is accompanied by his mother. You plan to suture the wound under procedural sedation using ketamine. a. List 8 contraindications to ketamine use in this setting. (4 marks) b. List 4 potential side effects/complications associated with ketamine use in this setting. (2 marks)

1. Parental refusal 2. Procedural required unsuitable for ketamine sedation 3. Inadequate staffing / area / equipment 4. Previous adverse reaction to Ketamine 5. Altered conscious state 6. Unstable patient: seizures, vomiting, hypotension 7. Cardiovascular disease - heart failure, uncontrolled hypertension, congenital heart disease 8. Procedures involving stimulation of posterior pharynx 9. Known airway instability or tracheal abnormality 10. Psychosis 11. Thyroid disorder or medication 12. Porphyria 13. Risk of raised intraocular or intracranial pressure 14. Active pulmonary infection or disease including acute asthma and URTI 15. Full meal within 3 hours (relative contraindication only, balance risk against urgency of procedure) Side-effects/Complications: 1. Airway obstruction 2. Nystagmus 3. Muscle rigidity 4. Random movements (can resemble seizure like activity) 5. Vomiting (during or after procedure) 6. Emergence phenomena 7. Apnoea 8. Failed procedure (need for a General Anaesthesia) 9. Hypersalivation

Name 4 complications of defibrillation. (4 marks)

1. Skin burns 2. Myocardial injury and post defibrillation arrhythmias 3. Skeletal muscle injury /thoracic vertebral fracture 4. Electrical injury to the health care provider

How will you optimise transthoracic impedance while using a defibrillator for an adult patient? (2 marks)

1. Use pads 10-13 cm in diameter 2. Use conductive pads or electrode gels 3. Perform defibrillation when the chest is deflated(during expiration) 4. Apply pressure of 5kg for manual defib pads

What are four uses/indications of capnography in intubated patients?

1. Verification of ET tube placement 2. Titrating ETCO2 levels in patients (eg in patients with increased ICP) 3. Determining adequacy of ventilation 4. Continuous monitoring of tube location during transport 5. Gauging the effectiveness of resuscitation and prognosis during cardiac arrest

A 3 year old girl attends your department late one night. She has stridor but is alert, and has previously been well. a. Apart from croup, give 4 differential diagnoses. (2 marks) What features on history and exam make epiglottitis more likely. c. In a patient with suspect epiglottitis, what are your management priorities? (2 marks)

1. inhaled foreign body 2. epiglotitis 3. angiooedema 4. tracheitis. Epiglottitis: Not immunised Acute onset of illness Toxic/shocked appearance Very high fever Drooling Cough minimal or absent Low pitched stridor c. In a patient with suspect epiglottitis, what are your management priorities? (2 marks)

c. Give 4 aspects of the scoring system to evaluate croup. (4 marks)

1. recession 2. stridor 3. air entry 4. cyanosis mental state

What is the treatment for post-thrombolysis bleed.

1. •immediately stop thrombolytic infusion 2. •administer 10 Units of cryoprecipitate IV 3. •transfuse 1 adult dose platelets 4. •administer protamine if recent heparin given 5. •consider transfusion of 2 units FFP 6. •consider aminocaproic acid or tranexamic acid

b. List 4 potential side effects/complications associated with ketamine use in this setting of suturing a head injury in a 4 yr old. (2 marks)

1/2 mark each up to 2 marks from the following: Airway obstruction Nystagmus Muscle rigidity Random movements (can resemble seizure like activity) Vomiting (during or after procedure) Emergence phenomena Apnoea Failed procedure (need for a General Anaesthesia) Hypersalivation

A 4 year old boy is brought to your ED having sustained a 4cm eyebrow laceration following a fall at a playground. He is accompanied by his mother. You plan to suture the wound under procedural sedation using ketamine. a. List 8 contraindications to ketamine use in this setting. (4 marks)

1/2 mark each up to 4 marks from the following: Parental refusal Procedural required unsuitable for ketamine sedation Inadequate staffing / area / equipment Previous adverse reaction to Ketamine Altered conscious state Unstable patient: seizures, vomiting, hypotension Cardiovascular disease - heart failure, uncontrolled hypertension, congenital heart disease Procedures involving stimulation of posterior pharynx Known airway instability or tracheal abnormality Psychosis Thyroid disorder or medication Porphyria Risk of raised intraocular or intracranial pressure Active pulmonary infection or disease including acute asthma and URTI Full meal within 3 hours (relative contraindication only, balance risk against urgency of procedure)

Infant with fever and SVT. What is the energy for DCCV. What is the dose of adenosine. List 4 investigations you would perform in the ED and their justification. (4 marks)

1J/kg. Consider amiodarone 5mg/kg if unsuccessful. Adenosine 0.1mg/kg increase by 0.5mg/kg every 2 mins to a max of 0.3mg/kg. BSL/glucose - prolonged tachycardia could cause hypoglycaemia, hypoglycaemia as cause of floppiness FBC - anaemia leading to circulatory collapse, inc or dec WCC (sepsis) Electrolytes/renal function - potassium/calcium/magnesium - deficiencies leading to arrhythmia CXR - look for cardiomegaly/signs of CHD/myocarditis, signs of LVF, focal infection Septic screen (blood culture, urine, consider LP) - sepsis as cause of SVT Urine toxicology screen - as cause of arrhythmia

Name the indications for FFP transfusion. Does FFP have to be cross-matched. What is in FFP.

Acc to wiki: 1. Replacement of isolated factor deficiencies with active bleeding or prior to surgery. 2. Reversal of warfarin effect. 3. Massive blood transfusion (>1 blood volume within several hours) 4. Use in antithrombin III deficiency. 5. Treatment of immunodeficiencies. 6. Treatment of thrombotic thrombocytopenic purpura (TTP) - although LiFL says TTP should be treated with prothrombinex usually in conjunction with plasma exchange. FFP contains all the vitamin K dependent clotting factors. 4 factor 4 factor prothrombinex concentrate also has factors 2,7,9 and 10 Recombinant or Factor VIII concentrates should be used to replace Factor VIII and not FFP as FFP does not contain factor 8!. FFP must be ABO compatible. Rh factor need not be considered. There are no viable leukocytes so plasma does not carry a risk of CMV transmission or GVHD. FFP has an INR of ~1.6 -> cannot lower below INR 1.7 Usually, there is an increase of at least 1.5 times the normal PT or PTT or an INR ≥ 1.6 before clinically important factor deficiency exists. This corresponds to factor levels <30% of normal. In a 70 kg Patient: 1 Unit Plasma increases most factors ~2.5% 4 Units Plasma increase most factors ~10% Usually an increase in factor levels of at least 10% will be needed for any significant change in coagulation status, so the usual dose is four units, but the amount will vary depending on the patient's size and clotting factor levels. Hematology consultation is advised concerning the dose of plasma.

You have just intubated a 75 year old 60kg woman with deteriorating respiratory function after a fall causing isolated closed chest injuries. She has a history of COPD. She has become increasingly hypoxic and hypotensive since intubation. Your hospital does not have an intensive care unit. a. List 8 causes for her deterioration (4 Marks)

Anaphylaxis Ventilator failure / O2 disconnect ETT misplacement / blockage Pneumothorax (iatrogenic or traumatic Breath stacking / hyperinflation Lack of synchronisation / need for paralysis Haemothorax Worsening pulmonary contusions

5 yr old intubated for asthma. What settings would you use for each of: RR TV PIP PEEP I:E ratio After connecting to the ventilator the patient suddenly deteriorates becoming progressively hypotensive and tachycardic. Give three possible causes. (3 marks) What is your first step in management? (1 mark)

Answer (first 2 mandatory)- 1. dynamic hyperinflation/gas trapping, 2. tension pneumothorax, 3. effect of induction agents, 4. other (hypovolaemia, equipment failure - tube dislodgement/O2 not connected) What is your first step in management? (1 mark) disconnect the patient from the ventilator/hand ventilate

A three year old child is brought in by her mother in with the presenting complaint of vomiting. Her initial observations are: Temp 37C, PR 120, normal colour, RR 18, Oxygen saturation 99% R/A, GCS 15, pupils 3mm, briskly reactive. After 10 minutes in the waiting room the triage notes that she has a staggering gait. You are called to review her in the CIN room. She is pale and drowsy with generally reduced tone, PR 88, RR 10, pupils 2mm and slightly sluggish. (a) Outline 5 essential steps in her resuscitation (20%) (b) Apart from ingestions list 4 potential aetiologies for her presentation (20%) (c) List 5 potential toxicological aetiologies for this presentation (20%) (d) You learn that her mother had given methadone to settle her behaviour. What is your response? (20%)

Answers (a) Outline 6 essential steps in her resuscitation (20%) Resus area Call for assistance Immediate stabilization/resuscitation Oxygen, open and maintain airway (jaw thrust) and support ventilation (PPV by BVM prn) Monitoring IV access, check BGL and collect bloods (FBC, EUC, LFT, B/C, ethanol) and crystalloid bolus NS 20mls/kg, assess response and repeat prn Marking. 25% of the total for question 18 Pass/fail (zero), Need 6 of bold to pass (20%). 2% for each additional up to 25% (b) Apart from ingestions list 4 potential aetiologies for her presentation (20%) Metabolic - hypo/hyperglycaemia Hypo/hypernatraemia Hypoxaemia Sepsis - CNS/systemic Trauma—head Organ failure - uraemia, hepatic Dehydration Brain tumour Marking. 25% of the total for question 18 (c) List 5 potential toxicological aetiologies for this presentation (20%) Clonidine Narcotics Antipsychotics and antihistamines Tricyclics Alcohols Hypotensive agents, eg beta-blockers, verapamil, diltiazem Hypoglycaemic agents Marking. 25% of the total for question 18 5% each item (d) You learn that her mother had given methadone to settle her behaviour. What is your response? (20%) Protect the child (admit) Protect other children in her care (DOCS notification, urgently by phone) Prevent repeat episodes (DOCS notification) Review the child for other evidence of injury (and record evidence of neglect that you see) Paeds involvement Marking. 25% of the total for question 18 Pass/fail Pass needs to include all the above (25%) Overall pass = 60%

Name an antihistamine and dose that can be used for anaphylaxis in a 12 month old. After a period of observation you decide to discharge the child with a prescription for an EpiPen. List 3 important pieces of discharge advice. (3 marks)

Antihistamine - Cetirizine 2.5mg or chlorpheniramine 2mg. Educate how and when to use EpiPen (action plan) Warn about biphasic reaction. Watch for return of symptoms - administer epipen and return immediately to ED - call 111 Avoid all foods with peanuts (read labels/ask when eating out) +/- tree nuts See GP in 24-48h for review

What are the targets to titrate fluid therapy? (4 marks)

Any 4 from the following - Physiological - SBP 90, MAP > 65mmHg, HR <100 Perfusion - UOP > 0.5ml/kg/hour, Lactate <2mmol, resolving base deficit, Cap refill < 4s Invasive measurement - Cardiac Index >2.5 L/min/m2, Pulmonary Artery Occlusion Pressure > 15 mmHg.

A child returns from a malaria prone area. What is important in history and exam. What Ix should be done. What defines severe malaria. What is the treatment for severe malaria.

Any patient with a fever who has returned from an endemic malaria region (See CDC for more information) in the previous 12 months should be assessed for malaria (even if prophylaxis was taken). History Full history with particular attention to Travel history, including location, places of transit, urban vs. rural Whether malaria prophylaxis was taken and, if so, which drug and compliance Prior empiric treatment for malaria Physical examination Full examination with particular attention to clinical features of severe malaria hepatosplenomegaly jaundice severe pallor respiratory distress Investigations Definitive diagnosis 1. Thick and thin film - thick film is used to confirm the presence of parasites and percentage of erythrocytes containing parasites, thin film is used to identify Plasmodium species 2. Malaria antigen/ICT - detects P. falciparum with >90% sensitivity, but is insensitive for other species or when there is a low level of parasitaemia. Both tests are required: 1 ml blood in EDTA tube is sufficient for both Note: A single negative film or antigen does not exclude malaria - thick and thin films should be repeated with fever spikes until positive test or 3 negative films. Other investigations Consider (depending on likelihood of malaria and severity) FBC, U+E, LFT Blood glucose Blood cultures Blood gas Coagulation profile Group and hold Sickle status CXR Severe malaria is a medical emergency. The presence of one or more of the following clinical or laboratory features classifies a patient as having severe malaria. Clinical features: 1. impaired consciousness or coma (cerebral malaria) 2. unable to sit up without assistance 3. vomiting or failure to feed 4. seizures 5. respiratory distress 6. shock/severe dehydration 7. haemoglobinuria 8. spontaneous bleeding (e.g. epistaxis, gum bleeding) 9. oliguria Laboratory features: 1. hypoglycaemia (blood glucose <2.2 mmol/l) 2. metabolic acidosis (plasma bicarbonate <15 mmol/l) 3. severe normocytic anaemia (Hb <70g/L) 4. hyperparasitaemia (>2%, though low peripheral parasitaemia is possible in cerebral malaria) 5. hyperlactataemia 6. renal impairment Treatment of severe malaria: ABC: Caution with treating fluid balance/shock as vulnerable to fluid overload with cerebral and pulmonary oedema Anti-malarial therapy - start intravenous anti-malarial medication urgently - Artesunate 2.4mg/kg IV, then repeat at 12 hours and 24 hours. Quinine if artesunate not available. Hypoglycemia - can be exacerbated by intravenous quinine, follow Hypoglycaemia guidelines and ensure ongoing dextrose if requiring maintenance IV fluids Address other complications including: Seizures - treat as per Metabolic acidosis Severe anaemia Acute pulmonary oedema Acute renal failure Spontaneous bleeding or coagulopathy All cases of P. vivax, P. ovale or unknown species should have liver hypnozoite eradication treatment.

A pt comes into ED by SJA in VF. What are your immediate actions? (8 marks)

Assume leadership, delegate roles Ensure continuous BLS provided throughout Manual biphasic shock 200J Continue CPR 2 minutes During CPR: Check electrode position Secure IV access Adrenaline 1mg and repeat after second shock and every second loop Correct reversible causes (4Hs,4Ts) Advanced airway Amiodarone 300mg after 3rd shock Post-resuscitation care/12-lead ECG/reperfusion

What does this ECG show. What are the causes.

Atrial paced rhythm with 100% atrial capture and second degree AV block with Mobitz I conduction (Wenckebach phenomenon). Wenckebach phenomenon is usually due to impaired conduction at the level of the AV node (unlike Mobitz II where the site of block isinfranodal), and may be seen with the following conditions: - Increased vagal tone (athletes, young children, painful stimuli) - Valvular heart surgery (especially mitral valve sugery) - AV nodal blocking drugs (beta-blockers, calcium channel blockers, amiodarone, digoxin) - Inferior MI

Causes of hypocalcaemia Symptoms ECG changes Treatment

Causes of hypocalcaemia: Vit D deficiency (muscle pain and weakness and osteomalacia in adults/rickets in chidren) Renal impairment Malabsorption Hypoparathyroidism Hyperventilation Hypomagnesia Symptoms of hypocalcaemia - Tetany, carpopedal spasm, colicky abdo pain, urinary frequency, seizures. ECG - Prolonged QT Treatment - 10 mls of 10% calcium gluconate, may repeat twice PRN. - Magnesium repletion essential - Vitamin D

Intubated woman needs to be transferred to a tertiary hospital for ongoing management. A retrieval team will arrive in 2 hours to transfer her by fixed wing. You do not need to supply staff for the retrieval. Outline how you would prepare for this transfer. (2 marks)

Communicate with receiving team - where is she going who will be responsible?(0.5) Prepare the patient - lines, medications, avoid pressure areas, ETT, catheter_(0.5 Prepare notes / xrays_(0.5) Ongoing monitoring and care of patient while awaiting retrieval team (0.5)

List 2 indications for non-invasive ventilation. (1 mark) List 4 contra-indications to NIV. (2 marks) What is the mechanism of action of NIV? (3 marks)

Indications: 1. Acute pulmonary oedema 2. Respiratory failure (will accept COPD as alternative) Cameron, p21 CI: 1. Coma 2. Combative patient 3. Inability to tolerate tight-fitting mask 4. Lack of trained staff to institute and monitor NIV Mechanism of action of NIV: Controlled FiO2 at set positive pressure - Recruits alveoli that were closed improving VQ match Increases pulmonary compliance, decreasing work of breathing.

A 50 year old man presents to your ED with palpitations.On examination, you have found him to be in atrial fibrillation with a rapid ventricular rate. 1.List your criteria for consideration of this man for cardioversion in the ED. (4 marks) 2.List 2 drugs you could use for chemical cardioversion. For each drug, give the dose and 2 contra-indications. (8 marks) 3. List 3 drugs you could use intravenously for rate control. For each drug, give the dose. (6 marks) 4. How would you assess this man's risk of thrombo-embolism? (1 mark)

Criteria for DCCV; Haemodynamic instability Definite onset AF within 24-48 hours Lack of known structural heart disease Non-chronic AF Correctable or no clear precipitant Pt preference Rhythm control: - Flecainide 2mg/kg - you need a normal ECG essentially and no history of heart disease: CI in known LV dysfunction, intra-ventricular blocks (eg BBBs) second- or third degree AV block, or with right bundle branch block when associated with a left hemiblock (bifascicular block). Flecainide is contraindicated in cardiac failure and in patients with a history of myocardial infarction who have either ventricular ectopics or non-sustained VT. - Amiodarone 300mg - iodine allergy, hypotension, thyroid dysfunction, long QT, marked sinus bradycardia or 2nd or 3rd degreee HB. - Sotalol 40 - 80mg - long QT, asthma, hypotension Rate control: - Metoprolol 2mg aliquots ,max 20mg - Verapamil 2.5-5mg aliquots, max 20mg - Digoxin initial loading dose 500mcg Risk of stroke (thromboembolic event): Either CHADS2 or CHA2DS2-Vasc score Age, diabetes, HTN. CCF Prior stroke/TIA Vascular disease (PVD, IHD) Being female! The CHADS2 score is one of several risk stratification schema that can help determine the 1 year risk of an ischemic stroke in a non-anticoagulated patient with non-valvular AF. CHADS2VASc: C Congestive heart failure (or Left ventricular systolic dysfunction) 1 H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)1 A2 Age ≥75 years 2 D Diabetes Mellitus 1 S2 Prior Stroke or TIA or thromboembolism 2 V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1 A Age 65-74 years 1 Sc Sex category (i.e. female sex) 1 Score of 0 (males) or 1 (females) = no anticoagulation Score of 1 (males) = consider starting warfarin or NOAC Score 2 = start warfarin or NOAC. Therefore anyone over 65 should be considered to start warfarin or NOAC.

What is kussmauls sign.

Paradoxical rise in JVP on inspiration: - Tamponade - PE - RV failure

Unstable VT, what are the possible causes (4 marks) and how would you treat it. What are the ECG features suggestive of VT vs SVT with aberrancy.

Differentials: 1. VT 2. SVT and BBB 3. Antidromic AVRT Cardiac Ischaemia Electrolyte - hypokalaemia, hypomagenesemia Drug - eg tricyclics Primary arrhythmia Congenital - HCM, right arrhythmogenic dysplasia. Cardiomyopathies Infiltrative diseases. Treatment of unstable VT: - Sedate - fentanyl 25mcg boluses, midazolam 0.5 - 1mg boluses - Synchronized DC cardioversion - 100 - 200J - Correct underlying cause VT suggested by: 1. Very broad complexes (>160ms). 2. Absence of typical RBBB or LBBB morphology. 3. Extreme axis deviation ("northwest axis") — QRS is positive in aVR and negative in I + aVF. 4. AV dissociation (P and QRS complexes at different rates). 5. Capture beats 6. Fusion beats 7. Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen. 8. Brugada's sign - The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms. 9. Josephson's sign - Notching near the nadir of the S-wave. 10. RSR' complexes with a taller "left rabbit ear". This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller.

Neonatal resus. When should adrenaline be given and at what dose. Should fluids be given.

Dry, warm, stimulate. Clear airway if necessary. Adrenaline 10-30mcg/kg - ongoing HR <60 despite BVM and initial CPR. IV fluid - 10mL/kg - ongoing HR <60 despite BVM and CPR Consider PTx.

Name 5 ECG changes in TCA overdose. Name 3 CVS changes in TCA overdose and their mechanism.

ECG - prolongation of the PR, QRS, and QT intervals; - nonspecific ST-segment and T-wave changes; - atrioventricular block; - right-axis deviation of the terminal 40-ms vector of the QRS complex in the frontal plane; - R wave aVR > 3mm or R:S ratio > 0.7 - right bundle-branch block; and the Brugada pattern. • Prolongation of the QRS duration >100 ms predicts a higher risk of arrhythmia CVS affects: 1. Arrhythmias and AV block (sodium channel blockade) 2. Hypotension (alpha blockade) 3. Tachycardia (anticholinergic)

Inferior STEMI. What are the ECG changes with right ventricular infarct. What arrhythmias are assx with them. How are they treated.

ECG shows Inferior STEMI with third degree heart block and slow junctional escape rhythm. Signs of right ventricular infarction: STE in V1 (and V4R) - nitrates CI. Up to 20% of patients with inferior STEMI will develop either second- or third degree heart block. The conduction block may develop either as a step-wise progression from 1st degree heart block via Wenckebach to complete heart block (in 50% of cases) or as abrupt onset of second or third-degree heart block (in the remaining 50%). Patients may also manifest signs of sinus node dysfunction, such as sinus bradycardia, sinus pauses, sinoatrial exit block and sinus arrest. Similarly to AV node dysfunction, this may result from increased vagal tone or ischaemia of the SA node (the SA nodal artery is supplied by the RCA in 60% of people, the AV node is supplied by RCA in 80%). Bradyarrhythmias and AV block in the context of inferior STEMI are usually transient (lasting hours to days), respond well to atropine and do not require permanent pacing.

A child has the following rash: Multiple lesions of different sizes Discrete lesions, no confluence Erythematous macules Target lesions with central clearing (CRITICAL TO PASS) Distribution over anterior right arm and forearm and anterior right side of thorax shown Child appears well perfused What is the diagnosis. List the 2 most common aetiological groups responsible for this rash, and 4 specific agents in each group. (6 marks)

Erythema multiforme Drugs - sulphur antibiotics, anticonvulsants, NSAIDs, cephalosporins Infectious - mycoplasma, HSV, other viruses eg EBV, fungal infections (no other groups acceptable)

What exam findings may help differentiate btw AMI, pericarditis, PE and dissection.

Fever-pericarditis more likely Pericardial effusion/tamponade signs -muffled HS, raised JVP (pericarditis) Pericardial rub -pericarditis more likley PE ->pleural rub, tachypnoea, hypoxia, calf swelling Dissection -r/r delay. Rfem delay, AR murmur, focal neurol, unequal BP arms

A 2 month old with query meningitis. List and justify the medications you would use to treat this child.

GOS = glasgow outcome scale.

You are the duty consultant. A 30 year old patient is being brought in by the paramedics as a Priority 1 patient (ETA 5 mins). He was found hanging by his friend at home. Initial rhythm was PEA. The paramedics have been working on the patient for 55 minutes and the patient has not regained circulation. You have been informed that patient is intubated and there is an IO access in. 1. How will you generally prepare for the patient's arrival? (4 marks) 2. A decision was made to call off the resuscitation attempt immediately after patient arrival. Describe the next steps you will take, (6 marks)

How will you generally prepare for the patient's arrival? (4 marks) Likely to be a futile further resuscitation Gather the team (medical, nursing, scribe) Prepare ALS drugs and airway equipment Delegate the floor activities to the next senior Triage staff to accompany next of kin to relative's room Create a resus bed to receive the patient A decision was made to call off the resuscitation attempt immediately after patient arrival. Describe the next steps you will take, (6 marks) Leave all the lines and tubes in situ Death to be reported to the coroner Instruct staff not to handle the body Leave all evidence including clothing intact Thorough and complete documentation Information for next of kin/patient's GP

Anaphylaxis hypotension with angioedema. You have assessed the patient as not requiring immediate airway management. List your 2 main treatment steps. Give doses and endpoints. (4 marks)

IV fluid Normal saline 1L bolus (20mL/kg) repeat if needed, aiming for systolic >90mmHg or MAP >65mmHg Adrenaline Stat IM 500mcg, repeat Q 5min if needed If deteriorating, IV boluses 50mcg (i.e 10x less than the IM dose) Infusion start at 5-10mcg/min Aiming for - systolic >90, reduction in angio-oedema

You wish to educate his mother in spacer and MDI technique and in spacer care. List 6 points that you will cover. (3 marks, 0.5 marks each)

Shake the MDI vigorously Prime the spacer with 10 puffs of salbutamol (accept 6-12 puffs) Hold the spacer tightly against the child's face (may require two operators) Deliver 1 puff then wait for 6 breaths Deliver a total of 6 puffs Wash the spacer in warm soapy water Do not rinse the spacer Allow to drip dry

Interpret this ECG. The patient's blood pressure is 80 mmHg. Outline the key steps in managing his hypotension. (4 marks). Cardiologist advices starting a vasoactive drug. List 3 appropriate ionotrope/vasopressor and doses.

Inferior STEMI Complete heart block Possible RV involvement (STE III>II) Possible posterior involvement (Flat ST depression V2-3) Bradycardia Treatment: Main priority revascularisation - angioplasty / thrombolysis - (1 mark) Cautious fluid bolus -must acknowledge risk of pulm odema or use bolus <500ml -(1 mark) Atropine - likely to be ineffective Avoid / cease GTN Transcutaneous pacing Inotropes IABP - only acceptable if preceded by revascularisation Drugs (see NB below easy memory aid): - Dopamine 3-5 mcg/kg/min to maximum of 20-50 mcg/kg/min. - Dobutamine 2-5 mcg/kg/min to maximum of 20 mcg/kg/min - Noradrenalin 2 mcg/min up titrate to response Taken from Tintinalli's Emergency Medicine 7th Edition Chapter 54 Table 54-5 Pg 388 with Milrinone excluded. Consistent with management advice in Dunn Emergency Medicine Manual 5th Edition Vol 1 Chpt 28 Pg 440 NB Norad, adrenalin and isoprenaline (none of these for this case) 2-20 mcg/min Dopamine and dobutamine 2-20 mcg/kg/min

If you apply a magnet to pacemaker what happens. What are the three commonest pacemaker modes.

It goes to magnet mode, an asynchronus mode - AOO, VOO, or DOO. Risk of VT in this mode. Note this differs from magnet application to an Implantable Cardioversion Defibrillator (ICD) which results in defibrillator deactivation. Commonest PPM modes: 1. AAI Atrial pacing and sensing. If native atrial activity sensed then pacing is inhibited. If no native activity sensed for pre-determined time then atrial pacing initiated. Used in sinus node dysfunction with intact AV conduction. Also termed atrial demand mode. 2. VVI Ventricle pacing and sensing. Similar to AAI mode but involving ventricles instead of the atrium. Used in patients with chronic atrial impairment e.g. atrial fibrillation or flutter. 3. DDD Capable of pacing and sensing both atrium and ventricles. Commonest pacing mode. Atrial pacing occurs if no native atrial activity for set time. Ventricular pacing occurs if no native ventricle activity for set time following atrial activity. NB Remember to say if there is 100% atrial capture and 100% ventricular capture. The absence of paced complexes does not always mean pacemaker failure as it may reflect satisfactory native conduction. And you can get different QRS morphologies due to: - capture beats (the hearts own native beats) - fusion beats (when the ventricle is simultaneously activated by both paced and native impulses).

Her hypotension resolves although she has an ongoing high oxygen requirement and high ventilator peak pressures. You have a simple VOLUME cycled ventilator. List basic ventilator settings for this woman and outline your ventilation strategy. (4 Marks)

Lung protective ventilation. (1) Avoid volutrauma (1) Avoid barotrauma (0.5) Accept permissive hypercapnoea. (0.5) Use lowest FiO2 possible to avoid hypoxia.(0.25) Rate 6-10 min (0.25) TV 240-350mL (4-6mL/kg) (0.25) PEEP 10cm H20 (or higher) (0.25)

Long QT on ECG. List 3 important features to obtain from the history of presenting complaint. (2 marks) In a pt with diar what are the most likely causes. List and justify your immediate management priorities. (5 marks)

Medication history esp macrolides; antipsychotics; antihistamines, antiarrhythmics, antidepressants; diuretics --> hypokalaemia History of known congenital QTc Comorbid disease contributing eg thyroid dysfunction; IHD, myocarditis renal dis. Any diar or diuretics --> hypokalaemia. If diarrhoea: Likely hypo K (Mg or Ca); DDx drug use with impaired excretion eg ARF ; medication interaction; overdose; congenital cause; alcoholism (hypoMg); Management: At risk for arrhythmia Monitored bed IV access urgent VBG Avoid any meds that prolong QT Replace volume; monitor progress with UO, thirst, obs Replace electrolytes via IV infusion eg K+ 10mmol/hr Symptomatic Rx: antiemesis, analgesia Have Mg ready

A 2 week old term baby weighing 4kg is brought to the ED with difficulty breathing and floppiness. Her vital signs are as follows: HR 160 /min BP 65/35 mmHg Sat 83 % on air Temp 37.6 °C CRT 4 seconds She is lethargic, and will respond to voice. a. List 4 differentials for her presentation. b. List your treatment priorities in sequential order. (4 marks) c. You decide to intubate this baby. What 2 sizes of ETT will you prepare?

Must include - sepsis, congenital heart disease T trauma/NAI H heart (CHD), hypovolaemia E electrolyte imbalance M metabolic disease - CAH I IEOM inborn errors of metabolism. S Sepsis/infection F formula related I intestinal (volvulus/NEC) T thyroid S seizures Airway/breathing - airway manouveurs and oxygen - improve saturations, if persistent hypoxia will likely require RSI Treat shock - IV access, IO if unable and IV fluid - 10-20ml/kg bolus (smaller bolus in case of CHD), reassess and repeat Seek/treat hypoglycaemia 2ml/kg 10% dextrose Source control - Assume sepsis and empirically treatment with antibiotics - cefotaxime 100mg/kg and amoxicillin 50mg/kg If CHD strongly suspected - prostaglandin ETT = 3 + 3.5mm

What is the definition of neutropenia.

Neutrophils < 0.5 or <1.0 but expecting to drop to <0.5

Name composition of normal saline and Ringer's lactate. (2 marks)

Normal Saline - Sodium 154 mmol,CL 154, K+ 0, Ca++ 0 Hartmann's - Sodium 131mmol, Chloride 111mmol, K+ 5mmol, Ca++ 2 mmol, Lactate 29mmol

What is pulsus paradoxus.

Occurs in tamponade.

16 yr old boy with congenital heart disease. Describe his ECG. Name 5 potential causes for this appearance. (5 marks)

Paced rhythm rate 75 bpm Loss of capture Period of ventricular standstill Occasional ventricular ectopic/escape beats P waves rate 75 - 100 bpm, complete heart block Due to: 1. Lead breakage or displacement causing pacemaker failure 2. Fibrosis causing pacemaker failure 3. Electrolyte abnormality 4. Toxicological causes - Ca channel/B blocker/digoxin toxicity 5. Failure to capture/needs check of threshold for capture

Causes of sudden vision loss.

Painless acute persistent loss of vision: 1. central retinal artery occlusion (CRAO) - sudden onset, cherry red spot and pale optic retina. 2. central retinal vein occlusion (CRVO) - painless over mins, not complete loss of vision, assx with hyperviscocity and DM. 3. retinal detachment or hemorrhage vitreous hemorrhage optic or retrobulbar neuritis internal carotid artery occlusion Painful acute loss of vision: 1. acute glaucoma 2. endophalmitis 3. uveitis 4. keratoconus (vision can deteriorate rapidly and is associated with photophobia) Transient: - Amaurosis fugax - Migraine

Name 3 categories of rewarming with 2 methods in each category.

Passive external rewarming • Warm environment • Remove wet clothes and dry patient • Insulation blankets • Warm blankets Active external rewarming • Warmed and humidified air/O2 • Warm forced air blanket • Heat packs to torso/armpits/groin Active internal rewarming • Warmed IV fluids (43°C) - 1-1.5°C/hr • Lavage o Gastric - NGT warmed fluid o Bladder - IDC warmed fluid o Peritoneal - warmed fluid in/out peritoneal cavity o Pleural - warmed fluid in/out of pleural cavity same side; one ICC upper chest, one lower • Extracorporeal warming - ECMO 8-12°C/hr

What are the features of competence to give consent. Can minors give consent. Can a child's medical info be witheld from parents. What if you cannot get hold of parents to consent for treatment of a young child.

Patient features of competence to give consent •age - no absolute rules -18 years or older usually considered competent -14 - 17 years - variable -< 14 years - usually considered to be non competent •have the cognitive capacity to understand -the medical condition -the options for treatment -what is recommended -the potential adverse outcomes -the likelihood of these •usually have a MMSE score of > 20 •patients should be able to -accepted information as reality -retain information provided -paraphrase information -explain the possible consequences -indicate the major factors in their decisions and the importance assigned to them Minors •parents or legal guardians have power of consent •if age < 14 years - patient is usually considered unable to legally give consent •if parent not available to consent and unable to contact by telephone - treat by implied consent •if age 14 or older, living independently (may be difficult to define) and considered capable of making an informed decision -medical information cannot be supplied to others (i.e. parents) without the patient's consent •treatment of life saving nature may be given despite parental objections -guardianship agencies will need to be involved

Investigations for pericarditis. Who should be admitted.

Pericarditis: CXR - Pneumonia/pleural effusions in bacterial pericarditis - Malignancy - TB Echo - Pericardial effusion - Tamponade Troponin - 50% positive - If significantly high then myocarditis. - Needs cardiac monitoring if elevated. CRP - Raised in 80% ESR - Raised in immune and infectious causes. FBC - Lymphocytosis = viral - WCC usually < 13000 with viral or idiopathic Rheumatoid factor if arthropathy Blood culture and AFB if symptoms of TB. Viral serology and PCR. U and Es - Uraemia Admission if: Tamponade Large effusion >2cm = >500mls. Bacterial or TB pericarditis suspected. Raised troponin - cardiac monitoring. Treatment is: - NSAIDs and colchicine 500mcg per day if <70kg or 500mcg BD if >70kg. - Aspirin CI due to risk of haemorrhagic pericarditis.

What are the differences in the ECG of pericarditis and STEMI.

Pericarditis: Phase 1 •concave ST elevation in leads I, II, V5, V6 -no distinct J point -PR depression in 80% (most common in II) -importantly, there is usually no ST elevation in III or aVF as would be expected in an inferolateral STEMI -ST / T wave ratio > 0.25 •PR elevation in aVR •ST depression in leads aVR, V1, V2 •slight shortening of QTc -increased QTc suggests AMI Phase 2 •usually after many days to one week •ST segments normalise •PR depression present in 60% Phase 3 •T wave inversion •sinus tachycardia •low voltages •electrical alternans if tamponade present Main differential diagnosis Early repolarisation phenomenon -usually involves only leads V1-3 -ST elevation can be greater in II or III STEMI -usually regional pattern and does not commonly involve leads I and II simultaneously -ST elevation greater in lead III than II in 85% of inferior STEMIs -degree of ST elevation similar in II and III in most other cases -any ST depression in lead aVL in patients with significant inferior ST elevation is nearly100% sensitive and specific for inferior STEMI -essentially rules out pericarditis or early repolarisation! -prolonged QTc may be present

What are the causes of each of peripheral and central vertigo. Name 5 features on exam suggestive of central cause.

Peripheral: 1. BBPV 2. Labyrinthitis 3. Vestibular neuritis 4. Acoustic neuroma 5. Cerebella pontine angle tumour 6. Ototoxicity 7. Menieres disease 8. Barotrauma Central 1. Cerebellar CVA 2. Posterior circulation CVA 3. Cerebellar tumour 4. MS 5. Lateral medullary syndrome 6. Vertebral artery dissection 7. Vertebrobasilar insufficiency Central examination findings: Rombergs positive Vertical nystagmus Dysdaidochokenisis Dysarthria Limb weakness (foacl neurology) Truncal ataxia Absence of positional component (negative dix-hallpike test)

Acute ataxia in a child. Name the three most common causes. What features on history and exam help distinguish them.

Post infectious - acute cerebellar ataxia (ACA) Tumour Toxins - but cause consciousness 1. Acute cerebellar ataxia: - Most common cause of acute ataxia in children - Most commonly 2 - 7 years of age - Post-infectious autoimmune process (most commonly varicella; also mycoplasma, EBV, HHV6, Parvovirus B19, enteroviruses) - usually 5-10 days after prodromal illness, with or without exanthem - may occur after varicella disease or immunisation - Acute onset of gait ataxia, dysarthria, nystagmus, symmetrical - other signs less pronounced - Ataxia maximal at onset; usually improving within days, full recovery over 10 - 21 days (>90% by 2 months). 2. Toxins: All cause impaired consciousness. Ask specifically about: phenytoin, benzodiazepine, antihistamines ethanol, ethylene glycol, isopropanol essential oils complementary medicines Tumours 3. Brain tumours usually present with normal conscious level signs of raised ICP usually gradual onset, may present acutely due to haemorrhage into tumour. Neuroblastoma - paraneoplastic encephalopathy - progressive ataxia; myoclonus, opsoclonus.

Name 4 drugs MDAC be given for. Pros and cons of MDAC.

Pro: • increased effectiveness if large amount ingested or delay to drug dissolution ( SR, enteric coated, slow GI motility, formation of concretions) carbemazepine dapsone phenobarb quinine theophylline • Effective for drugs with enterohepatic circulation, High binding capacity, small Vd, low protein binding, drug not ionized at physiological pH Con: • ileus/ perforation/ obstruction • Decreased mental state or unprotected airway • More complications than single dose charcoal • Increased risk aspiration / obstruction/ perforation

What are the pros and cons of activated charcoal.

Pros • Cheap • Accessible • Easy to use Cons • Messy • Interferes with resuscitation • Time consuming • Corneal abrasions Single dose activated charcoal Pro • Useful if ingestion of potentially toxic amount of poison that is absorbed by charcoal. • Highly effective if < 1/24 from ingestion but if delayed gastric emptying extend out to 2-3 hrs. Con: • Vomiting • compromised airway or GCS unless intubated • absent BS • charcoal resistant poison ( eg lithium)

What are the causes of hypotension in aortic dissection. What is the ED treatment of aortic dissection. What are the indications for surgery.

Pt usually hypertensive. If hypotensive ensure it is not due to limb discpreancy caused by an occluded vessel - check BP in the arm with best radial pulseaortic rupture. Aortic regurg tamponade AMI - inferior MI most common, but can be any. end-organ ischaemia - brain, limbs, spine, renal, gut, liver death. Emergent priorities (1) control BP (2) control bleeding (3) fluid resuscitation - O2 - wide bore IV access (Swan sheath) - invasive monitoring - warn blood bank (x-match 6U + need for other products) - correct coagulopathy - control HR and BP (aim for P 60-80 and BP 100-120 SBP) IV beta blocker (propranolol, esmolol or labetalol) combined with vasodilators (e.g. GTN, labetalol, SNP) start b-blocker first to avoid increased aortic wall stress from reflex tachycardia. - call cardiothoracic surgeon Indications for surgery: - Persistent pain - Type A - Branch Occlusion - Leak - Continued extension despite optimal medical management

Unwell febrile elderly pt. List 3 key steps in this patient's management. (3 marks)

Resuscitation Screening / diagnosis e.g. blood cultures / biochemistry etc. Antibiotics - broad spectrum cover required Any two of: Source Control Monitoring Disposition Boundary of Care

What is the IV dose of salbutamol and magnesium respectively in children.

Salbutamol IV - 5-10mcg/kg bolus then infusion Also accept MgSO4 - 50mg/kg bolus then infusion

List the steps of preparation for rapid sequence induction. (5 marks)

Staff - assemble skilled team, call for expert help if required (anaesthetics/ENT) Equipment - appropriate size laryngoscope, ETT, syringe, tape, suction, oxygen, airway adjuncts and rescue plan for can't intubate/can't ventilate, Drugs - induction and paralysis agents, pressor, IV fluids with multiple, secure access. Patient - assess airway and C-spine, fasting status, allergies, medications; pre-oxygenate, optimise position Monitoring - continuous ECG monitoring, pulse oximetry, BP monitoring and end-tidal CO2 monitor

A child with mild asthma. One lot of 6 puffs of salbutamol and 1mg/kg prednisolone, then discharge +/- watch for 2 hours. List discharge criteria and advice you would give his parents. (3 marks, 0.5 marks each)

Sustained improvement with no requirement for salbutamol for > 2 hours No O2 requirement Adequate access to transport and phone Safe distance from hospital Competent and willing parents or caregiver No prior hx of ventilation or ICU admissions No prior hx of precipitous rapid decline Adequate community follow-up Action plan for parents - return if requires > 4 hourly salbutamol (accept range 2-4 hourly)

Causes of hypernatraemia.

Symptoms of hypernatraemia: Irritability Drowsiness Hyperreflexia, tremour, seizures Doughy skin Ataxia Causes of hypernatraemia: 1. Hypotonic fluid loss - Burns - GIT loss - diar - Sweating 2. Hyperaldosteronism - Primary - conns - Secondary - CCF, liver cirrhosis, nephrotic syndrome 3. Diabetes insipidus: Idiopathic •50% of cases of hypernatraemia Neurogenic •trauma •CNS infection •CNS tumour •neurosurgical •Guillain Barre Gestational •due to increased concentrations of vasopressinase -resistant to vasopressin -responds to desmopressin Nephrogenic •renal abnormalities -amyloid -medullary sponge kidney -polycystic kidneys -pyelonephritis •drug related -ethanol -phenytoin -lithium -dextropropoxyphene -amphotericin •electrolyte abnormalities -severe hypokalaemia -hypercalcaemia •congenital -rare -associated with optic atrophy and deafness - Wolfram's syndrome -caused by mutations in the vasopressin receptor or aquaporin-2 gene •myeloma •sarcoidosis Features of diabetes insipidus •polyuria •nocturia •serum osmolality > 290 mosmol/L •serum [Na+] > 145 mmol/L •urine osmolality < 150 mosmol/L 4. Iatrogenic - hypertonic saline, sodium bicarb. - inappropriate formula solutions, rehydration solutions. Ix: Urinary Na and osmolarity Plasma Na and osmolarity Seizures may be due to venous sinus thrombosis or cerebral infarction. Consider imaging with a contrast CT scan. Treatment: - Sodium > 170 = ICU referral, initial resus with normal saline, then replace fluid deficits (10%) over 96 hours with normal saline and 5% dextrose (paeds) or 0.45% saline in adults. - Sodium 150-170 = replace fluid deficits (7%) with gastrolyte via NG over 48 hours. Gastrolyte has a low Na concentration 60mmol/L. - Sodium 145-150 = no specific treatment. Rehydrate normally. - Desmopressin after fluid replacement. - Carbamazepine

What are the indications for reperfusion therapy (thrombolysis) in ACS. What drug is used in Austalia usually.

Tenecteplase which is a variant of tPA (which is used in stroke) - a single dose. 30-50 mg (weight based). Or double bolus reteplase 10 units over 2 mins, repeated 30 mins later, not weight based. Indications for thrombolysis in ACS: stemi, cardiogenic shock, refractory pain, refractory VT, repeat thrombolysis if <50% improvement in ST elevation at 90 mins. 1. STEMI - 2mm in 2 contiguous leads in chest leads. - 1mm in 2 contiguous leads in limb leads. 2. other high risk acute coronary syndromes without STEMI criteria -e.g. features of left main stem occlusion (Wellens T waves with ST elevation in aVR) 3. cardiogenic shock of ischaemic origin 4. following cardiac arrest with ROSC 5. haemodynamically significant ventricular arrhythmias resistant to treatment 6. failure of ST elevation to improve by 50% within 90 min. of commencement of thrombolytic therapy -required in approximately 35% of patients receiving thrombolytic therapy 7. ongoing pain uncontrolled by all standard therapies without STEMI criteria Time and reperfusion •most benefit when commenced < 6 hours following onset of symptoms •lesser benefit up to 12 hours following onset •> 12 hours if -haemodynamically unstable -ongoing symptoms Thrombolysis target: within 30 mins of ED arrival. PCI target: within 90 mins of ED arrival (120 mins acceptable).

Name the 4 causes of painful scrotal swelling.

Testicular torsion Torsion of the testicular appendix Epididymo-orchitis Inguinal hernia

Septic elderly pt. The patient is intubated for respiratory failure. List the four key components of your ventilation strategy for this patient? (2 marks) What PEEP would you set, what determines what PEEP to set and what is the upper limit of PEEP.

Tidal volume 6ml/kg Plateau pressure <30 cm H2O PEEP Titrated to FiO2 Minimum 5 cm H2O - Maximum 24 cm H20 FiO2 Titrated to Sats 88-95% or PaO2 55-80 mmHg Answers taken from Surviving Sepsis Campaign International Guideline for Management of Severe Sepsis and Septic Shock 2012 and ARDSnet NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary

List 4 indications for endotracheal intubation. (4 marks)

To create and airway To maintain an airway To protect an airway To provide for mechanical ventilation From Cameron, Textbook Adult Emergency Medicine 2009, p 20

What are the different types of transfusion reactions with blood transfusions. What is the management approach. What are the other complications of transfusions.

Transfusion reactions: •usually only life threatening if major ABO incompatibility (HAEMOLYTIC REACTION) •more commonly minor allergic or non specific febrile responses (NON-HAEMOLYTIC FEBRILE REACTION) Assessment HAEMOLYTIC REACTIONS •incidence 1:12,000-77,000 •shock •fever •headache •pain -at infusion site -back -chest pain •intravascular haemolysis •haemoglobinuria •ARF •DIC FEBRILE NON HAEMOLYTIC REACTION •incidence 0.1-1% •seen frequently multiparous women or in multiply transfused patients. •due to recipient antibodies to donor white cells •dose related •often occur towards the end of the transfusion •platelets and granulocytes associated most frequently with this type of reaction •symptoms appear 30 - 120 minutes after starting transfusion -can occur 1-2 hours after the transfusion has finished •temperature rise 1oC above baseline •hypotension uncommon Management •stop transfusion •check patient and blood product packs to ensure correct product is being administered Mild reaction •temperature increase < 1.5o C •no rash •no evidence of more severe features •recommence transfusion at slower rate under close observation Moderate reaction •hives •temperature increase > 1.5o C •no other features of more severe reaction •give anti-histamine and anti-pyretic •recommence transfusion after 20 minutes •cease transfusion if symptoms return -send repeat patient sample (10 mL EDTA tube) and blood pack sample to lab Severe reaction •stop transfusion •ensure adequate hydration •send repeat patient sample (10 mL EDTA tube) and blood pack sample to lab Complications of transfusions: 1. Transfusion reactions - Non haemolytic febrile reaction - Haemolytic reaction 2. Hypothermia 3. Clotting factor dilution 4. Hyperkalaemia 5. Anaphylaxis 6. Fluid overload 7. Delayed reactions: - TRALI 1-6 hours from start of transfusion - Infections

Describe 2 clinical situations when you might consider using an LMA in ED? (2 marks) How can you confirm the placement of this device? (3 marks) When might an LMA not work (5 marks)

Use • Cardiac Arrest • Failed intubation Confirm placement by: • It should rise when cuff inflated • Air entry to both lung fields • Capnography May not work with: • Non-fasted patients • Morbidly obese patients • Pregnancy • Obstructive or abnormal lesions of the oropharynx • Increased Airway resistance and decreased lung compliance

SVT in an infant who is febrile. What are your treatment options in order of escalation for the SVT. What Ix would you do in ED and why.

Vagal manouveurs - dunk head in ice water or cold face cloth dropped on face Adenosine IV 100mcg/kg (can double dose Q2min up to 400mcg) (Amiodarone IV 5mg/kg over 30 min) DCCV cardioversion - sync 0.25-0.5J/kg (with sedation). Investigations: 1. BSL/glucose - prolonged tachycardia could cause hypoglycaemia, hypoglycaemia as cause of floppiness 2. FBC - anaemia leading to circulatory collapse, inc or dec WCC (sepsis) 3. Electrolytes/renal function - potassium/calcium/magnesium - deficiencies leading to arrhythmia 4. CXR - look for cardiomegaly/signs of CHD/myocarditis, signs of LVF, focal infection 5. Septic screen (blood culture, urine, consider LP) - sepsis as cause of SVT 6. Urine toxicology screen - as cause of arrhythmia

What obs should be done if physical restraint used (3).

Vitals. Limb obs - pressure and perfusion. Bladder.

List 4 predisposing factors for intussusception.

Vviral illness, cystic fibrosis, benign or malignant bowel tumours- e.g. putz Jeager, Meckel's, coagulopathies e.g HSP- causing haematomas, sutures and staples, inverted appendiceal stump, Male gender

Name three pieces of information you would like to assist you in managing her refusal of treatment (3 marks). When any patient is deemed able to refuse treatment, what steps will you take to facilitate a safe discharge? (4 marks)

Why she is refusing. Is she competent. Is there a duty of care. Risks of refusing treatment vs risks of sedation Management of DAMA: 1. Address reasons for treatment refusal 2. Recruit others to assist 3. Attempt to compromise 4. Provide alternative care 5. Stall •use only as a last resort -e.g. waiting the arrival of a relative who is on your side -loss of patient trust means other methods are likely to no longer be effective •delay DAMA form signing 6. Use Police •if public safety compromised (i.e. driving whilst still intoxicated) 7. Arrange follow up 8. Encourage to return PRN. 9. Discharge at own risk form and documentation.