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Practice exams Flashcards

1
Q

Three potential advantages to parents being present during resuscitation?

Disadvantages?

A

Advantages
-Parents can see that all efforts have been made
-Improves ability to accept death and deal with grief
-Reduces risk of litigation
-Improves professional behaviour of staff
-Opportunity to say good-bye

Disadvantages
* Needs designated staff member to support family
* Potential for parental interference
* Distress for parents seeing invasive procedures and other intervention
* Increase stress for staff providing resuscitative care

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2
Q

List six (6) factors that should be considered prior to terminating resuscitation

A
  • Downtime prior to commencement of resuscitation (eg presence of rigor mortis)
  • Have all reversible causes been identified and treated
  • Underlying severe comorbidity or terminal disease
  • Severe biochemical derangement (pH< 6.8, K >10)
  • Has there been any response to treatment during resuscitation
  • Duration of resuscitation with no evidence of cardiac output
  • Persistently low end tidal pCO2 (less than 10-15mmHg)
  • Has a senior clinician been involved in managing the arrest (phone or in person)
  • Is there team agreement the further resuscitation is futile
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3
Q

Paracetamol toxicity?

A

Risk assessment
-> 200mg/kg or > 10g
-Survival guaranteed if NAC commenced within 8 hours
-Still treat with established hepatic injury as decreases morbidity (cerebral oedema and inotropic requirements) and mortality
-If present after 8 hours are commenced on NAC immediately while awaiting paracetamol and ALT levels (ALT < 50 normal)
-If double the nomogram line should have increased dose of NAC, double dose second bag

Stage 1 < 24 hours
-Nausea and vomiting or asymptomatic

Stage 2, 24-72 hours
-RUQ tenderness, hepatoxicity
-Transaminases may exceed 10, 000
-INR elevation
-Hypoglycaemia, hyperbilirubinaemia

Stage 3, 72-96 hours
-Fulminant hepatic failure with jaundice and encephalopathy
-Death can occur, associated with worsening lactic acidosis, progressive renal failure, severe coagulopathy and cerebral oedema

Stage 4, 4 days to 2 weeks
-Recovery phase

Decontamination
-Activated charcoal if present within 2 hours
-Also for massive ingestions > 500mg/kg if present within 4 hours

Patients fulminant hepatic failure require management in ICU and transfer to liver transplant service
Criteria include
-INR > 3 at 48h
-Oliguria or Cr > 200micromol/L
-Acidosis with pH < 7.3
-SBP < 80 or lactate > 3
-Hypoglycaemia
-Severe thrombocytopenia
-Encephalopathy

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4
Q

What are the Ellis classification of dental injuries how are they treated?

A
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5
Q

Ways to minimise pain with local anaesthetic?

A

Smaller diameter needle

Slow speed of infiltration

Smallest volume necessary

Warming solution

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6
Q

List four (4) risk factors for developing re-expansion pulmonary oedema

A
  • Large Ptx
  • Drainage of large volume >1.5L
  • Young patient
  • Lung collapse >7/7
  • Application of negative pressure (suction)
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7
Q

The patient states he is a Jehovah’s Witness and presents a written Advanced Care Directive stating that
he will not consent to treatment with blood products under any circumstances.

List three (3) criteria that must be fulfilled for this Directive to be valid

A
  • Written voluntarily / without coercion
  • Written when patient was competent/had capacity
  • Relevant to the current situation
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8
Q

You deem the best course of action is to focus on end of life comfort care.

Outline your approach to this situation with the daughter.

A

Private environment

  • Explanation of rationale of change of focus to comfort, maintaining dignity
  • Include pt if possible
  • Establish pt’s previous wishes, enquire about ACD
  • Stakeholders/family/priest/cultural rep
  • Engage treating teams
  • Social worker
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9
Q

Palliative care medications?

A
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10
Q

What are the four (4) cardinal signs of flexor tenosynovitis?

A
  • Tenderness along the course of the flexor tendon
  • Symmetrical oedema of the finger (“sausage digit”)
  • Finger slightly flexed at rest
  • Pain along the tendon on passive extension
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11
Q

Define cultural competency in health practice

A

Cultural competency is a set of attitudes, skills and knowledge that allow an individual to
interact effectively in cross-cultural situations

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12
Q

How can cultural competency be incorporated into practice?

A
  • Treating the patient with their specific cultural context in mind
  • Ensuring that the patient feels safe
  • Approaching those of other ethnicities with a mixture of empathy, respect, self-reflection and
    curiosity, ensuring that the patient does not feel judged based on their cultural background
  • Being aware of how our own culture impacts on our health practice
  • Knowledge of different ethnicities and their health statuses
  • Knowledge of different cultures and their beliefs and experiences around health
  • Continuing to improve your skills in these areas
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13
Q

What is the insulin rate for children < 5 with DKA?

A

0.05 units/kg/hr

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14
Q

Define Emergency Department overcrowding?

A

Situation where ED function is impeded primarily because the number of patients waiting to be seen,
undergoing assessment and treatment, or waiting to leave exceeds the physical and/or staffing
capacity of the ED

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15
Q

Other than access block, list six causes for ED overcrowding

A
  1. increased patient number (eg- a seasonal component like winters)
  2. increased patient complexity
  3. increased unnecessary patient evaluation/investigation
  4. delays in referral
  5. delays in-inpatient unit assessment
  6. delays in other services eg radiology, pathology, allied health (max 2 marks)
  7. ED staff factors eg-skills, numbers
  8. ED structure eg design/size
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16
Q

Define access block

A

Inability to access appropriate beds in a timely manner for emergency patients who require
inpatient admission quantified as the proportion of patients admitted, transferred to other
hospitals, or who die in the ED who have a total ED time (arrival at triage to discharge from the ED) of
more than 8 hours

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17
Q

List three broad recommendations made by ACEM (Australasian College for Emergency Medicine) to
ensure more effective and efficient patient care in Emergency Department.

A
  • demand reduction eg increased access to outpatient clinics, easier referral pathways
  • removing barriers to patient flow eg pull model, minimize investigations in ED
  • reducing hospital occupancy eg improved discharge planning, HITH options post discharge
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18
Q

Complete the table labelling parts of the under water seal unit?

A
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19
Q

Suggested pressures for patients with chest drain who require suction?

A

Suggested pressures for other patients who require suction -20cmH2O/15 mmHg

20
Q

What are two methods for measuring blood pressure in patients with an LVAD?

A
  1. NIBP is performed with a manual sphygmomanometer and Doppler ultrasound over
    brachial or radial artery
  2. Invasive mean arterial pressure can be obtained by placement of an ultrasoundguided
    arterial line
21
Q

List four initial first aid or topical measures that can be used to control anterior epistaxis?

A

Sit with head forward to prevent swallowing/ aspiration of bloodAdvise patient to spit out and
not swallow blood

Suction blood/ clots from the nares or ask patient to blow nose Topical Vasoconstrictors -
adrenaline/ co-phenylcaine / oxymetazoline
Continuous pressure to the anterior nares (cartilaginous part) for 15-20 minutes

Cautery with silver nitrate - do don’t apply to both sides of the septum

22
Q

List three factors on physical examination that suggests a posterior source of epistaxis?

A

Failure to visualize blood anteriorlyBleeding from both nares

Visualisation of blood in the posterior pharynx

Despite insertion of an appropriately sized Rapid Rhino, the bleeding remains uncontrolled.

23
Q

Management of life threatening bleeding on dabigatran?

A

Dialysis - Consider on setting of impaired renal function or dabigatran present inexcess as
indicated by aPTT > 80 seconds or a dabigatran level> 500 mg/ml

Reversal agent - ldarucizumab (Praxbind) 2.5g to 5g. Only indicated if thrombin time prolonged

TXA 15mg/kg IV

24
Q

List four possible factors in this man that would make his wound high risk and necessitate the need to
treat with antibiotics

A
  • *>8hour delay in review
  • puncture wound that can’t be adequately debrided
  • wound on hand
  • involving deep tissues- bones, joints, tendons
  • pt immune compromised or alcoholic, liver disease or DM
  • open #
25
Q

What are tetanus prone wounds?

A

Penetrating, older than 6 hours, extensive tissue damage, animal bites, chronic ulcers or wounds, re implantation of an avulsed tooth

26
Q

Management of tetanus prone wound?

A

Check tetanus immunisation history to see if completed primary course - three doses

If incomplete (no previous immunisation or incomplete primary course or unknown)

Tetanus vaccine if completed primary course and
-Prone wound and > 5 years since last dose
-Or clean wound but > 10 years since last dose

If < 3 doses or uncertain but clean/ minor wound
-Complete primary course

Tetanus immunoglobulin
-If < 3 doses or uncertain and tetanus prone wound
-Dose is 250 units IM or 500 units IM if > 24 hours or following burns
-Also give vaccine

27
Q

English is not a first language for this family.
List three techniques that may be used to facilitate good clinical communication in this case

A
  • Offer an interpreter or AHLO
  • Use engagement that is appropriate to the area the family is from - this might include talking to
    family/elders, avoiding eye contact, offering gender specific staff
  • Slow down, use plain English and allow time for questions
  • Offer culturally appropriate written or illustrated information
  • Involve culturally specific health services for discharge planning and follow up
28
Q

Aside from corrosives, list three classes of agents including an example, where activated charcoal is
unlikely to be beneficial after an acute exposure.

A
  • Metals (lithium iron)
  • Hydrocarbons (eucalyptus oil)
  • Alcohols (methanol, ethylene glycol)
  • Pesticides
  • Solvents
29
Q

What is absolute risk reduction?

What is relative risk (risk ratio)?

What is relative risk reduction?

A
30
Q

Analyse this forest plot?

A
31
Q

You review the notes from his presentation 2 days prior, when he was seen by one of the registrars
during the night shift. He had a low-grade fever, was complaining of 9/10 pain and had elevated
inflammatory markers with CRP 100. The impression was of muscular back pain with drug seeking
behaviour. He was discharged home with no follow-up planned.
You discuss the case with this registrar.
List key elements of your approach to this situation.

A
  • Ensure privacy
  • Be professional
  • Recognise that this can be a challenging diagnosis that is often missed at first presentation
  • Recognition of risk factors, which this patient had
  • Maintain high suspicion of the condition if risk factors present
  • Overnight pt can be admitted to ED short stay for senior review next day
  • Learning opportunity - brief education on the condition, investigation & management
  • Red flags of back pain presentations
  • Consider notifying medical defence organisation
  • Notify HOD, DEMT, mentor
  • Discuss biases, patient advocacy
  • Offer support
32
Q

Fill in the risk assessment table for valproate?

A
33
Q

Clinical features of valproate toxicity?

A

Coma

Lactic acidosis - HAGMA

Hypernatraemia, hypoglycaemia, hypocalcaemia

Hyperammonaemia

Renal impairment, hepatotoxicity

Hypotension

Cerebral oedema is the life threatening complication

34
Q

Investigations with valproate overdose?

A

Serial valproate levels to confirm poisoning and requirement for haemodialysis

In comatose patient repeated every 6 hours until normalised

Ammonia levels to correlate with severity and duration of coma

Urea and electrolytes, LFT’s, calcium, lipase

35
Q

Valproate level and clinical effects?

A

> 500mg/L coma is likely

> 1000mg/L increased risk of life threatening cerebral oedema

36
Q

Management of valproate toxicity?

A

Activated charcoal if ingestion > 400mg/kg if present within 2 hours

If CNS toxicity only after intubation

Enhanced elimination
-Haemodialysis if ingestion of > 1000mg/kg
-Serum level > 1000mg/L
-Severe toxicity with progressive lactic acidosis, cerebral oedema, hypotension

37
Q

What are the major and minor criteria for endocarditis?

A
38
Q

Complete the table below for the 3 stages and features of ethylene glycol toxicity.

A
39
Q

State three (3) indications for giving activated charcoal in the setting of paracetamol overdose

A

Acute single ingestion >10g or 200mg/kg of immediate release < 2 hours post ingestion
* Massive (>30g) acute single ingestion immediate release paracetamol < 4 hours
* Acute single ingestion >10g or 200mg/kg of modified release paracetamol <4 hours post
ingestion

40
Q

You read a cohort study examining the prevalence of this condition.
Complete the following table detailing the differences between prospective cohort and case-control
studies

A
41
Q

State six (6) SPECIFIC risks posed to older patients attending an emergency department.

A
  • Pressure Injuries
  • Delirium
  • Falls
  • Nosocomial infections
  • Medication Errors (due to polypharmacy)
  • Diagnostic error (due to atypical / subtle presentations of disease)
  • Under-recognition of pain (accept under-treatment of pain)
  • Not aligning ED care with existing patient goals of care
  • Under-recognition of the impact of frailty (see definition) as high risk for admission
  • Increased risk of communication in handover to/from community care-givers (e.g. interim
    medication orders, discharge communication, outcomes of discussions)
42
Q

Thinking about emergency department design, state six (6) SPECIFIC features that can prevent harm
for an older person accessing ED care.

A
43
Q

The patient deteriorates significantly. Despite this, they want to leave against medical advice.
State four (4) principles that need to be met for a patient to be detained under the mental health act

A
  • Person appears to have a mental illness
  • Because of that mental illness they need immediate treatment to prevent serious
    deterioration in their physical or mental health (or serious harm to another person)
  • If made subject to act is able to be assessed
  • There is no less restrictive means to safely manage the patient
44
Q

State six (6) distinct reasons why patients experiencing an acute psychiatric illness are at an
increased risk of medical illness.

A
  • Self-neglect e.g., starvation, dehydration, deficiencies.
  • High risk behaviours e.g., Trauma, assault, STIs, etc.
  • High rates of concurrent substance abuse.
  • High risk of ETOH or substance withdrawal.
  • Suicide attempts / intentional overdoses.
  • Higher rates of chronic illness due to lifestyle / social determinants of illness.
  • Exacerbations of chronic illness more likely.
  • Concomitant social dysfunction; exacerbating access to health care.
45
Q

What are 5 actions you would take if a nurse complains about the conduct of a registrar?

A

I. Patient safety – assign another doctor to care for patient
II. Take registrar off duty – personal/sick leave
III. Arrange for safe transport home
IV. Arrange appropriate medical follow up & professional support (eg VDHP)
V. Notify ED Director/Medical Services
VI. Consider need for open disclosure with patient/family
VII. Document carefully / incident report
VIII. Arrange support for nurse

46
Q

Degree of frostbite injury.

A

1st degree – numbness, erythema, oedema, desquamation, dysethesia
2nd degree – blisters
3rd degree – tissue loss of entire thickness of skin
4th degree – tissue loss beyond skin (ie deeper structures)

Final month (7 decks)

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