ED Formative Flashcards
In the assessment of paediatric fever in the emergency department, which statement is most correct?
- A: All febrile neonates should have a septic screen and admission
- B: Fever is defined as a core temperature of >37.00C
- C: Fever of >40.00C will lead to convulsions
- D: If paracetamol abolishes the fever, it is unlikely that the source is a bacterial infection
- E: In children aged between three and 36 months, bacterial infection can be excluded on clinical grounds alone
= A: All febrile neonates should have a septic screen and admission
- A: Compensated respiratory acidosis
- B: Metabolic acidosis
- C: Metabolic alkalosis
- D: Respiratory acidosis
- E: Respiratory alkalosis
= B: Metabolic acidosis
- Metabolic acidosis is correct. pH= 7.25 = acidaemia PC02 is low so not a respiratory
cause.
Based on current guidelines, which therapy in treating cardiac arrest has the most supportive evidence?
- A: Closed chest compressions
- B: Defibrillation according to ALS guidelines
- C: Intravenous bretylium
- D: Open cardiac massage
- E: Use of thrombolytic therapy
= B: Defibrillation according to ALS guidelines
- The only therapy demonstrated to influence survival. Some evidence re closed chest compression but not the most supportive cf defibrillation. Bretylium has disappeared from the ALS guidelines No supportive evidence re open cardiac massage and use of thrombolytic therapy.
Regarding paracetamol overdose, which statement is correct?
- A: A single ingestion of more than 50 mg/kg is potentially fatal if untreated
- B: AST may increase within 12 hours of toxic ingestion
- C: Children are more susceptible to toxicity
- D: Elevated INR may occur without raised liver enzymes
- E: Use of N-acetyl cysteine (NAC) is ineffective 16 hours or more after ingestion of a toxic dose
= B: AST may increase within 12 hours of toxic ingestion
- The AST may increase within 12 hours so this is correct. Usual toxic dose is greater than 150 mg/kg. Children are not more susceptible.
Associated with hepatic injury so liver enzymes are elevated N-acetyl cysteine (NAC)can be used up to days after the toxic ingestion with benefit
In a patient with a suspected Addisonian crisis, what electrolyte series would support the diagnosis?
- A: Low sodium, low potassium and high blood glucose
- B: Low sodium, low potassium and low blood sugar
- C: Low sodium, raised potassium and low blood glucose
- D: Raised sodium, low potassium and low blood glucose
- E: Raised sodium, raised potassium and high blood glucose
= C: Low sodium, raised potassium and low blood glucose
What is correct regarding opioid drugs?
- A: Drug tolerance can lead to absence of miosis
- B: Morphine is a good analgesic choice in renal failure
- C: Morphine-6-glucuronide is an inactive metabolite
- D: Naloxone has a half life of 120 minutes
- E: Pethidine may be associated with seizures
= E: Pethidine may be associated with seizures
A 24 year old male sustains a self-inflicted laceration at the wrist. What physical sign would be associated with a median nerve injury at that level?
- A: Inability to abduct the fingers
- B: Inability to abduct the thumb
- C: Inability to adduct the fingers
- D: Inability to adduct the thumb
- E: Inability to flex the terminal phalanx of the thumb
= B: Inability to abduct the thumb
- An injury to the median nerve at the wrist will cause loss of abduction and opposition of the thumb.
- Interossei function so ulnar nerve - inability to abduct and adduct fingers.
- Supplied by the ulnar nerve - inability to adduct thumb.
- Long thumb flexor has a proximal supply - inability to flex terminal phalanx of the thumb.
Following an acute myocardial infarct, what cardiac biomarker is present in the serum earliest?
- A: CKMB
- B: Lactate dehydrogenase troponin I
- C: Myoglobin
- D: Troponin I
- E: Troponin T
= C: Myoglobin
Myoglobin - rises earlier than CKMB or troponin. MB is being used in most cardiac biomarker panels in EDs now in an attempt to risk stratify earlier. CKMB present within 10-24 hours. Lactate dehydrogenase troponin I peaks at 72 hours. Troponin most sensitive around 6 hours.
What drug is used in the emergency department that does not cross the placenta?
- A: Diazepam
- B: Heparin
- C: Phenytoin
- D: Promethazine
- E: Salicylates
B: Heparin - can be safely used in pregnancy as does not cross the placenta.
What can a normal anion gap metabolic acidosis be caused by?
- A: Addison’s disease
- B: Chronic antacid use
- C: Diabetes mellitus
- D: Methanol
- E: Uraemia
= A: Addison’s disease
Addison’s disease is correct. Low levels of aldosterone lead to sodium wasting and H+ retention in the distal renal tubule. This can be deduced by the common causes of an anion gap metabolic acidosis MUDPILES. Chronic antacid use causes a metabolic alkalosis.
Diabetes mellitus, methanol and uraemia - part of MUDPILES.
While walking in Northbridge, a 33 year old male is transferred to the emergency department after a stab wound to the back. He has a right lower limb paralysis and decreased sensation to pain and temperature on the left below the waist.
The findings are most consistent with which cord syndrome?
- A: Anterior cord syndrome
- B: Brown-Sequard syndrome
- C: Central cord syndrome
- D: Complete spinal cord transaction
- E: Horner’s syndrome
= B: Brown-Sequard syndrome
- Brown-Sequard syndrome is the only choice that produces spinal hemiplegia. All others are not consistent. Central cord syndrome - upper limb weakness greater than lower limb weakness.
A 69 year old female, with a prior history of hypertension, presents with tearing interscapular chest pain. The ECG shows evidence of an acute inferior myocardial infarction. The chest X-ray is unremarkable.
After initial assessment and stabilisation, what is the next step?
- A: Administer a thrombolytic agent
- B: Administer aspirin followed by streptokinase
- C: Obtain an elective MRI of the chest
- D: Obtain an urgent CT angiogram of the chest
- E: Start heparin
= C: Obtain an urgent CT angiogram of the chest.
- Acute thoracic aortic dissection can present in this manner- the first coronary artery to be affected is the right coronary in a proximal dissection so an inferior AMI pattern may be a feature.
What is the most significant early complication of a pelvic fracture?
- A: Life threatening haemorrhage
- B: Pelvic abscess
- C: Rectal laceration
- D: Sacral plexus injury
- E: Urethral injury
= A: Life threatening haemorrhage
A. Life threatening haemorrhage is the major cause of death - important to reduce the pelvic volume with external binders as an initial life saving measure.
A patient returns from an ultrasound of his right lower limb as investigation for a suspected deep vein thrombosis. The report states a ‘thrombosis is present in the superficial femoral vein extending to the saphenotemoral junction.
What is the best management?
- A: Anticoagulation with heparin while waiting for a therapeutic warfarin level
- B: Elevation, local heat and aspirin
- C: TED (compression stocking)
- D: Thrombolysis as primary treatment
- E: Vascular surgical review for thrombectomy
= A: Anticoagulation with heparin while waiting for a therapeutic warfarin level
- Anticoagulation with heparin is correct. This is a deep vein thrombosis- the nomenclature of referring to the femoral vein as the superficial femoral vein is largely superseded but an important source of confusion in a clinician thinking it is a thrombosis of a superficial vein.
With regard to the use of bedside ultrasound in the setting of trauma, which statement is correct?
- A: Assessment of the IVC filling can be used to gauge resuscitation
- B: Blood is able to be distinguished from ascites
- C: Sensitive to exclude parenchymal injury to solid organs
- D: Sensitive to rule out bowel injury
- E: Supine chest X-ray is more sensitive to diagnose a pneumothorax than an ultrasound
= A: Assessment of the IVC filling can be used to gauge resuscitation
- Assessment of the IVC filling can be used to gauge resuscitation is correct. - The IVC filling and variation with respiration can be used to assess the degree of volume filling.
- Bedside ultrasound can detect free fluid in the abdomen, pleural and pericardial spaces.
- Unable to determine the nature of the fluid.
- Ultrasound performs better than a supine CXR to diagnose a pheumothorax.
In the diagnosis and treatment of diabetic ketoacidosis, what is correct?
- A: Cerebral odema occurs most frequently in children presenting for the first time with new onset diabetic ketoacidosis
- B: Insulin therapy should be delayed until there is adequate volume resuscitation
- C: Never occurs in patients with type Il diabetes mellitus
- D: Potassium replacement should start at the onset of resuscitation
- E: Serum sodium is commonly greater than 150 mmol/L (RI: 134 - 146)
- A: Cerebral odema occurs most frequently in children presenting for the first time with new onset diabetic ketoacidosis
- What has happened? (0.5 marks)
- What urgent intervention is required? Outline a comprehensive systems approach and include the dose and method of administration of any medications. (7.5 marks)
- Anaphylactic reaction (anaphylaxis) (0.5 marks)
Male, older, family history, hypertension, hypercholesterolaemia, diabetes mellitus. (0.5 marks each, max 3 marks) (Total 3 marks)
An ECG was taken just after arrival (refer to ECG shown). Describe this ECG. (3 marks)
- Sinus rhythm 97/minute (1 mark)
- ST segment elevation lead V1-V5 (1 mark)
- Axis left axis -42 degrees
- P wave normal
- PR interval, QRS narrow, QTC normal (0.5 marks each)
(Total 3 marks)
Diagnosis = Acute myocardial infarction (0.5 marks) anterior STEMI (0.5 marks) (Total 1 mark)
The patient has further pain and you elect to do another ECG (refer to ECG shown). What is the new development that is evident from this ECG? (1 mark)
Accept VT, or torsades de pointes, or coarse VF (Total 1 mark)
